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What you’ll hear in this episode:

• What hormone therapy is
• The difference between bioidentical and non-bioidentical hormones
• How genetics come into play

Today Dr. Khris Ramdeen is joined by Dr. Andy Ruiz, the president of Stonegate Pharmacies, to talk about the widely discussed topic of hormone therapy. Hormone therapy is often used to add hormones that are missing in the body such as when men experience low testosterone. It can also be used by women who are lacking the hormones needed due to menopause to help offset the side effects.

Bioidentical hormones are lab-made and identical to the hormones our bodies naturally produce. They are prepared by pharmacists to be as natural as possible so they’re metabolized properly by the body. These hormones are different than commercial hormones produced by big pharmaceutical companies. The main difference is non-bioidentical hormones need to be activated, but bioidentical hormones are compounded to be a near-perfect match to the body. Because non-bioidentical hormones need to be activated, they have the potential to cause issues for certain groups of people.

There are many different factors that come into account when doctors are deciding if and what sort of hormone therapy is correct for the patient. They look at different conditions that the patient may have, lifestyle, and their genetics to see what is best for them. It is often not just the doctor involved in these decisions. They usually work as a team with nurses and pharmacists to decide the best plan.

Listen to the sixth installment of Apple a day Doc Talk with Dr. Ramdeen to hear more of his discussion with Dr. Ruiz to learn more about hormone therapy and everything that goes into it. If you enjoy what you hear be sure to share with friends and family. you can find more Apple a Day Doc Talk here!

Apple a Day Doc Talk is a founding_media podcast created in partnership with Dr. Khris Ramdeen.

Host: Dr. Khris Ramdeen

Guest: Dr. Andy Ruiz

Find Stonegate Pharmacy on Instagram

 

Transcript:

this is a founding media podcast if Hey guys welcome to apple and a doctor I’m your host Dr Rehm dean and we have a very special episode today we have a doctor Ruiz hearing aid the Ruiz hi Andy how you doing thank you for having me so he’s from Stonegate pharmacy here in Austin and San Antonio correct a couple of pharmacy yes Sir and we’re gonna talk about today’s testosterone replacement therapy this is a very popular topic right now and there’s a lot of questions that we’re getting asked for in the internal medicine and primary care side of things and I’m sure you as well indeed correct about this all day so I wanted to introduce to India a little bit here and tell you why we’re so lucky to have him today he is actually a very critical resource to me for hormone replacement therapy and a lot of docks in the area I know a lot of stocks console with you about things like mode if prescriptions and and topical versus sublingual verses injection and you you lecture quite a bit just want to tell the audience a little bit about your background and your partner at the Stonegate pharmacies here here in Austin and San Antonio and co founder of endl tech solutions and what’s in the tax ID

interred tech is a platform a website that we streamlined to wear it empowers patients to just fill out a questionnaire and kind of give some feedback on where they are on their hormonal status and then it connects them with providers and pharmacists throughout the United States and then so it’s really a patient power metal axle India’s very very data driven I know he’s always talking about still fits in here D. A. the more data the better exactly I totally agree with that that’s why I like him and India attended the university of Texas at Austin for two years prior to entering the university of Texas at Austin college of pharmacy where he earned his doctor of pharmacy in two thousand eight after you finish that he existed in the design and implementation of the first combined master of science in pharmacy in community pharmacy residency he was also the first trainee the American society of health system practices accredit residency completed and after completing that the combined master of science residency program you joined and independently far an independent pharmacy in San Antonio where you were the wellness director and pharmacist in charge right at the corner store specialty and home infusion pharmacy correct as we did at all yeah he is not even a third of the way through what I’m we have introduced a year but in may of two thousand eleven any move to Austin here and soon after assumed his role as a business partner and pharmacist in charge is still get pharmacy and as president and he oversees all operations of the Stargate pharmacies he enjoys teaching academic inter professionally intra professionally and at the university of Texas at Austin college of pharmacy teaches both elective and didactic courses as an adjunct assistant professor and Dr Louise also serves as an adjunct assistant professor for midwestern University College of pharmacy and faculty preceptor for incarnate word university Fike school pharmacy are you get hired in August it’s no in addition any lectures for various chemical companies on hormone replacement therapy therapy for men and women in these a fellow and serves as an instructor for the American college of apothecaries where he teaches advanced courses in men’s and women’s health and just to give you a little bit of his research background in two thousand ten and he published as a read original research on bio identical hormones which is you know very common question right now about what is by identical we’ll get into that but prior to two thousand ten indie published original research on infectious disease served on the board of the international academy of compounding pharmacists foundation and served as the foundation’s research committee chair he’s currently a member of the national community pharmacists association Texas pharmacy association American college of apothecaries and alliance of independent pharmacists of Texas Indies also active in researching this current research is focused on safety and efficacy of various routes of administration for bio identical hormone replacement therapy in menopausal women and he’s hoping to start a new study on the utility of sublingual hormone replacement therapy

having going like this having said all that you can see why I feel really lucky to have ended here today that’s all we’re talking about today’s hormone replacement specifically with testosterone in men and women if there’s anybody I want to talk to about this it was you ended not only because absolutely not only because of your background but I know that just locally you are the main resource for this amongst us well you have to work with the best I mean so I mean your practice what you preach and you know I can’t do the things that I want to do if I don’t get to work with the best and brightest out there so I appreciate being here for some form of thank you so much indeed and let’s dive into it and

the first question one of the most common questions especially when someone is a candidate or or wondering if their candidate for testosterone one of the first questions I get is what does bio identical means that’s a great question because you know when I was first doing my research back in two thousand eight on you know we called bio identical hormones I was pretty lame bastard for using that term because you know it’s the best term that we use more of our yes very openly however you know if you want to get scientific I saw molecular would better maybe be a better term or natural hormones but to be fair they’re still synthesized as most things that we have in our day to day lives so it’s not like I get your hormones and pull him out of your blood and given to somebody else right the reality is there still chemically made in a lab and they have to meet certain standards of purity to even be utilized but all that the net the bio identical hormones really mean our natural hormones that are identical to the hormones that our body produces and our job as pharmacist is to advise and prepare medications that they can be utilized in the most physiological or natural means possible for your body’s this way they’re metabolized properly they’re absorbed properly and they’re utilized properly throughout the body so basically the more they look like the real thing exact they’ll act like three exactly and can you tell me what the differences between the bio identical testosterone testosterone maybe that are not labeled yes so let’s use like you know and there’s a lot of natural hormone replacement therapy out there that is commercially available so when I mean commercially available it’s something that a big pharmaceutical company would make verses what we make our custom medications right or compounded medications and so is anybody’s wondering what is a compounded medication what’s compounding ask your grandparents when an apothecary is we’re going to a party carrying you’ll see this this older gentleman in a white coat generally not behind glass like we do now or doors and a help a filter there but you see the mixing things and that’s you know for lack of better words it’s we’re making things from scratch but do you know the bio identical hormones coming commercial the available forms like Val dot which is an estradiol patch or they can be compounded so there’s there’s different means but there when we discuss the commercially available non bio identical you have Sabean it relishes USM’s testosterone sipping natives a dime the injections commercially available by the way that’s one of the most common I also write a distraction is an injection and if you think about it what does the biggest difference is that C. B. N. eight has a has a for like it’s call the kind you get so it’s assault form that’s attached to it that your body has to cleave off right that’s not necessarily bad if you think of B. vitamins they have to be activated it’s a similar fashion with testosterone Serbian eight has to be activated the only cabbie out that you come into these types of parameters is if you think of the difference between estrogen and testosterone if if I had a picture I can show you the the difference which is almost if you look at it you think it’s the same for the layperson almost a hundred percent time it’s like oh it’s exactly the same but those small changes on those molecular structures can generally have a significant effect throughout the body so arm order methodology with using bio identical is let’s use exactly what the body produces so this way we can provide that same natural outcome versus relying on genetic factors or or bacteria to cleave and break off these conjugates which that’s a whole different topic but certainly none that is really helpful thanks to him so basically what you’re saying is with bio identical you basically have these patients by pass us that exact awards acidification act right right right so let’s just keep it simple okay and which is let’s not rely on the body to activate things if if I needed

so let’s say this there’s a patient that is deciding between a bio identical here or non by identical there and they’re looking at price may be and and they’re wondering okay if I do this formulation that’s not bio identical and I have to quote you know cleave that Sandra fought group off myself what what are some of the concerns are what should patients look out for who would be the types of patients that may not do as well because they did not choose the bio identical so in some cases if they have microbiomes of gut digestive issues sometimes which you’re thinking when you’re gave me an injection why would that matter right we rely on the bacteria in art in order to G. I. system to really convert a lot of hormones over and to recycle these hormones writes of you having just GI issues and that could be a factor in some cases if you don’t metabolizing hormones properly so if you have you know we refer to as MTHFR conditions or other genetic factors they may not be as rapid converter let me stick around a little bit longer or they may not utilize it is efficiency or in some cases you may convert it more rapidly over to estrogen mmhm which is that is important to point isn’t it Andy where the testosterone you take is peripherally converted court just moon transformed into estradiol karez in estrogen and what you’re saying is you don’t want that to happen too quickly because then you’re gonna have the exact opposite effect correct awesome correct answer for you guys out there like me and I’ve been on testosterone and I felt like a rockstar maybe for the first two weeks maybe the first month in office and you had this regression there’s a good chance it’s converting over to estrogen or it’s not being metabolized appropriately in you know we may talk about these things rather off the cuff firm you know simplified but these are pretty advanced topics that you know start to ram dean was saying that we’re still learning we’re still it’s still involving the literature still coming out to how do we properly address these things so it’s important to empower yourself and to really start you know looking into what is my health what is my genomics what is my how my eating right you know since we’re taking a deep dive here in order to change it it’s it’s really

another who who he important question I get is let’s say you have someone you know the testosterone level looks great they’re doing well otherwise but now they’re strict aisles creeping up and they might need to be on a blocker to prevent that talk about what you know what I teach nurses yeah yeah so and and so I have had me my purse so personally I like Dr ending it was a beautifully putting how I over you know take on more than I should the interest you know it’s stress can be something that induces are aromatization right so meaning that it converts over just awesome to estrogen and I myself have been a victim to that in the sense that it’s self inflicted in in a lot of cases let’s be real it’s nothing that you can I can just go sit on the beach for a month or just relax and sounds nice but you know there’s reality here but the same time as we convert over more testosterone to estrogen one of the natural properties of estrogen is we crave sugars which induces fat bloke deposits in our in our lower abdomen upper hip so it’s this adding fuel to the fire that’s just not easily just take the bull by the horns kind of concept you have to be active and conscious of the decisions were making to further addresses and in some cases medications are very necessary so you know we we see medications like clump and anastrozole or letrozole and with these are they’re called aromatase inhibitors right so you’re preventing the conversion of testosterone to estrogen however I like the doctrine dean was alluding to estrogens are very important and men as well as women so in in men if we don’t if we drop artist on our Esther dot Esther dial too rapidly or too much he may prevent ejaculation and may prevent climax it could cause lower lumbar osteopenia so which Yasser process in the in our lower back kind of thing so these medications are important but under the supervision of a skilled practitioner such as decorating that we want to make sure that we’re keeping a close eye on these things are not just buying them off the internet and pop in on because I’m trying to lean up because the outcomes can be rather a detrimental from even a cardiovascular perspective so right in decreasing estrogen too much and and basically what you’re saying India is that obviously you don’t want your estrogen level to be higher Esther dial right will be high but you don’t want to overdo it in suppressing its formation right and the best way to do that would be to use the lowest possible dose is high infrequently as possible you guys so you don’t just blasted down see a low estradiol level and be like yeah we’re good on this you know that the whole go start low and go slow philosophy so you were fine tuning it and and that’s where you know our society as a whole may kind of work against us that instant gratification some things that are worth it are worth waiting for so as we titrate up to be patient to be understanding that this is a process

and is there a dose and frequency you find work well for men and women to start like an aromatase inhibitor that’s a great question because a like a well first and foremost there there are certain products that are kommer are out there that are natural supplements that are touted for blocking aromatization in the natural supplements art out there truthfully while there’s been some anecdotes and you’ll see it all over the website all over the internet there there have not been proven to be effective in the literature so can you give us some examples so I actually I’m I’m thinking as I’m talking right the the one I’m thinking of comes from passion flower ricin yes equities crisis and so it is advertise all over the internet all over the health stores the reality is so one of the courses I used to teach was supplements course for men’s health and I wanted passionately to prove that there is something out there that works it’s natural and I could not find is I had a bias right only kind of work there’s got to be something you know like this is crisis is an example I’d rather leave that beautiful pile flour of passionfruit loan rather than destroyed to give chase and because what the research is showing that while it works in in in vitro studies meaning in a Petri dish where they destroy the cell membrane exposes the inner enzymatic reactions it doesn’t work in humans were in vivo right that’s when you read in vivo studies so when you when that happened tons of research showed one human body you either don’t absorb it or it’s not working so the reality is those natural supplements haven’t really been shown to be effective with regard to stopping aromatization can you talk about him a little bit so anyhow I was chosen to yeah we just gonna do him in some of the other and what does that stand for do you know so die in the stall of Matt yeah it’s okay it’s it’s basically it’s a gore it’s X. concentrated broccoli extract right and it has an enormous the tall in it component which you’ll see more and more come out such as choline is as well right so Coleen meaning found in eggs you find high concentrations of Innoson tall and derivatives thereof in broccoli and what those do is they really do help the estrogen go down the proper channels and what I mean by channels as you as your body’s metabolizing these hormones think of it as a four right so if it’s a fork facing downwards in the hormones are being metabolized down specifically yesterday right the most Visy logically active estrogen and both men and women you wanted to go down that left pathway that two hydroxyl pathway and that pathway isn’t is initiated by dim so dim is a great starting tool in going down that pathway as that pathway for veers off to that left for work with the healthy side it splits again so here’s where the other co factors that you’re alluding to come into play such as manganese such as copper such as N. acetyl cysteine or cystine which is another essential amino acid throughout though our whole absorption of green leafy vegetables right so eating at this where this whole eating healthy comes into play because if you think about Brussel sprouts or spinach or any other green leafy vegetable that is grown in the dirt it’s it’s absorbing these nutrients such as manganese manganese copper zinc selenium bills can go on and on of all these S. B. vitamins are just grown in in your wrist and and and really amplified in these vegetables so it’s important to eat as much of that is possible but supplementing our diet with those things as well to ensure that we’re having the proper met metabolism so this is where that genomic aspect comes into play in the in the larger complexity of what we’ll refer to as farm could genomics of how are we metabolizing hormones properly and in dim was of a huge ground breaking into that direction and and it’s been around for a very long time and to be fair we had some idea but it was a positive anecdotes that were accepted in the profession of a dim works kind of like ashwagandha we don’t know how it works but it it does in some day we’ll find out but is one of the few that will anecdotally recommend and now the research is blowing up on it and it’s amazing and now with such as a provider such as Dr Randy who can go in and start looking at genomics and identifying your testosterone levels on point but now we’re looking at genetic factors to understand why you may not be responding ideally and let’s fine tune those thing right and so it’s a collaborative effort that team effort that did he was referring to that we learn from each other and that’s so important I talked in the old time you know especially with the new patient we do strategizing L. what’s the latest research what are their genetics look like what are their levels and even the mode of administration which will talk about a little bit but let’s zoom out of the elevator so everyone’s head rest stop hurting exam to home who

the question I wanted to ask too is who’s a good candidate for replacement therapy so you know it the the the prime candidate that you that we I guess textbook candidate right would be I’m a male generally ge let’s just say testosterone generally over the age of fifty five that has serum testosterone total testosterone under three hundred and expresses certain symptomatology which will also get a free testosterone right reality Russian there’s various ranges of candidates and it can be as young as as the thirties when that individual is really entering their professional careers and lives in stress is catching up with them age is catching up with them and I always joke that once I passed thirty that’s when I noticed things were starting to so it was it it’s really hard to to identify to be fair on how to treat them even on them I’m sure when you’re seeing the patients you know it is this individual screaming for low testosterone and and you’re right the the the reason why it’s so hard to answer is because this is a multi factorial assessment it’s not just opening numbers to ninety nine boom Stranraer fake so because there’s a range of three hundred eight hundred rail and there’s you know symptoms like low libido low energy loss of lean muscle mass increase fat you know concentration difficulties there’s plus you know the number that you see exactly really do have to put the whole picture together you nails and and and and aside from that you know looking at risk factors like to have a really bad controlled sleep apnea do their island club Stevie tease P. ease prostate issues that might preclude you at least temporarily until you get those things under control from doing that so it is not just here’s your number caress your testosterone really do have to look at every correct and and take and take the health care into your own hands because providers such as Dr Randy in can only do so much they can provide the tools to to patients as myself and I experience these things but if I didn’t take you know the proverbial bull by its horns certain life under control then his hands are tied so it is a true team not just pharmacists physician nurse practitioner P. whoever it may be but truly the patient being in in the center of that team because there there’s a quarterback if you will of how we’re gonna go

absolutely and can you mention men but this is growing in terms of use for women to right after that it’s so you know just like estrogen in men at first it was like why would you even talk about that right but it is very important in in men but same thing with women if their testosterone siliceous simply put is a woman goes through menopause their ovaries cease to function right so to start fresh produce in the ovaries without testosterone their cardiovascular couldn’t disease risk goes up their sex life is dim in the quality of life in general is just as effective as well so if that affects our relationship is so it’s not just about mail in testosterone and and their libido right that also has an effect on women’s health too so you know you and I talked about that you can’t necessarily try to fix one without helping fix the other price so in in women E. you’re seeing all different types of forms being utilized for testosterone where they’re being injection or sublingual or pellet or cream there’s just in all different forms and and avenues for treatment of these conditions as well that are just being utilized significantly right right and so yeah I just wanted to mention that that this is a problem they have to and yeah it was it wasn’t too taboo but maybe even five years ago right like okay it’s coming hours disc wing what does this mean but it’s been pretty establish and pretty throughout the medical literature as well as in the health care community this is system portent that we just have to properly work it up in and monitor it with the skill provider such as Dr MD

right right and so what are some of that we talked about some of the risks but obviously benefits and and I wanted to reiterate the risks you know if you are thinking about doing this or already on it you really should know about your prostate health I like a check PSA or prostate level in your blood tested right going up then we’re gonna have to either reduce it stop it have you see a role just and if you have sleep apnea and it’s not controlled or if it was previously controlled and now you’re on testosterone and that’s getting worse that’s another red flag that we need to kind of pull back or because what we’re doing and then that’s a great point of because a lot of men think testosterone fixes my sleep apnea right you can also have the opposite effect like you’re saying so that’s a great point that you brought up right with the testosterone cap weight loss which would be beneficial for you right after you but you can also harm you and stimulation overthrow police’s you known take into your blood increases your hemoglobin and hematocrit and that can cause you to have blood clots deliveries in your legs or currently costs in your lungs or pulmonary embolism so if you’ve already had those things are you predisposed to having those things these are definitely something you need to go over with your doctor or even cancers like estrogen receptor positive breast cancers for example if you’re going to be converting that testosterone to estradiol and now your estrogen levels are high you don’t want to run that risk and not tell your doctor in advance is not even a candidate to to tell you the truth and you know and what’s a what’s interesting is this is where I think these genetic tests are coming into play even for men is I learned I was a carrier for breast cancer and you know you don’t think of that in men generally but men can develop breast cancer but at the same time what if I have a daughter who did she inherit those genes to she inherit that risk so it is important to think about the immediate but as well as long term affects in discussing that with your doctor your provider and to really understand Hey you know what where my in this whole a spider web of endocrine and then my candidate for testosterone or any hormones in general for it and if not what can be done yeah I mean and

and let’s talk about the benefits now so why take it yeah I mean as you know like I said earlier testosterone let’s just say it improves the overall quality of life measures but it also helps overall with the cardio vascular cardiovascular disease osteoporosis and so the effects that it has or or broad reaching not to mention that if you if you take away testosterone you general in men specifically you generally take away estrogen so it’s not just so coal rectal cancer goes up so you really have to think about how does this affect the overall state of the body because they they have a an intricate working relationship I mean it’s so it’s almost like the holy Trinity with the estradiol testosterone and progestin because progesterone is critical in minutes well right so you we don’t really think of those interactions together but that those three together either convert or interact with each other right and what I like what you’re saying again here too India’s because we’re trying to educate on this but it’s still suit very complicated right so you need to look at everything and and one thing I’ll just say as a side note is that sometimes people doing this without any medical supervision yeah getting testosterone from a friend or something like that obviously we don’t want you to do that and but when someone like that comes in obviously have them stop it because because there’s other labs that ARE all right their cholesterol may be off their liver function their kidneys action the Esther dial may be off the charts and and I actually got a call from a colleague last weekend for a who’s a hospitalist and they know that you know I I’d this is all I do everyday so they called me because the young guys in his early fifties had a stroke testosterone level was off the charts was getting it from his friend and so there we go with that stimulation of the retro polices correct causing your blood to clot and it may manifest as a heart attack not that it causes cardiovascular disease but you can totally block off that blood vessel right that’s feeding your heart and that can happen anywhere can happen your brain can be a stroke so you do not want to do this and say all my testosterone levels great there are so many other things that we need to look out for when you’re in for when you know exactly for men I mean let’s get real like you say you can start anywhere think of your microscope Edie generally is the first sign of of mice microvascular concern so if you’re taking testosterone and uncontrolled unsupervised it can lead to E. D. in some regard if you’re sticking in your blood in it clogs up that microvascular teacher so if if that’s what it’ll help you think about Hey maybe and you go see a doctor please this is a risky so the writers get real there and then when you say microvascular says little blood a little less and it exactly and so I just wanna yes yeah I don’t know just want to stress the importance of monitoring and not to saying okay I’m taking testosterone I went to some random let my testosterone levels high feel awesome right no right that that is not the whole story and you make it really permanently hurt yourself if you have a stroke or heart attack and we don’t want you to do that it you know in in

you know for myself like I’m I’m young high I go see my provider regularly in it and you know I talked to my family and they’re like you’re healthy what’s the deal and it’s because it’s important to just monitored to be taken care of and to ensure that overall health is being supervised absolutely and he he alluded to the modes of therapy Andy can you talk about the different ways testosterone can be a minute yeah the most common it’s air injection creams and sublingual tablets now or or B. equals what we’ll call in where you put him in either between your cheek on your tongue and when I say injection egg that can even include Helen to just simplify okay sure but the most common probably right now is injection when you do the topical route do you feel like absorption issues are is absorption issue in terms of market lab monitoring it totally did yeah that’s a can of worms yeah I like the question so if he’s a if done properly we can overcome these barriers to some regard but the skin is a bear here the skin is designed to protect and keep things in and out so when we put things on our skin intending to absorb in whom we have to understand we’re trying to bypass a barrier the biggest organ in our body so I’m not a massive fan of topical that’s how I first started though so I didn’t have much respect for that route of delivery and in some cases it works phenomenal but that’s where I take the cues from the patient because of that’s the route they want then that’s kind of where we’re going with and that’s my our job is when you say they want this here’s our level what can we do we try to figure out how can we bypass the skin how to penetrate through the skin to get that desired outcome and educate as much as possible to do the pros and cons of we’re gonna try our best if it doesn’t work let’s be open to another chance and come along

common question I get to just with the sublingual and buccal verses injection or in hell it is is this going to be harmful to my liver that’s a great question because some of the early nineteen fifty studies on methyl testosterone ironically was on three patients I believe had demonstrated that liver toxicity when swallowing the reality is when given an attribute cool or sublingual fashion it bypasses the liver a hundred percent because of the vascularity in the world because our our mouths so we have about conservative ninety percent absorption the rest of it is metabolized have similar enzymes in our mouth that we do in our stomach that are in inert inactive and so they don’t hurt us so the absorption is phenomenal and it is very different from moral and I think that’s something that as patients need we all need to understand the difference of that of sublingual from moral excellent excellent and talk about how the talk about the importance of a balanced regimen for optimal outcomes no that’s a great point because even with my provider was extreme stress if I have sleep disturbances or my life is full of stress and then I will utilize projects from because of the new role properties of of protection that it provides for the down feeding into testosterone that it provides so it is important for balance regimen of when I monitor my hormones that cause of stress that I may not have too high of testosterone or too low of estrogen or not enough projects room per se but it invests in man so think about the female body in the complexities of it of when we’re drawing the labs and when we’re looking at these levels and overall how is it a balanced regimen to ensure the overall team work of these hormones right because their team they’re working for for us to optimize our house in talking about balancing in the intermingling of hormones just coming up with all these common questions but particularly men will say Hey do I need to be on H. C. G. two or even women mass I heard H. CG causes weight loss tell yeah H. U. G. H. T. D. is interesting in its most simplest terms it mimics luteinizing hormone which comes from up to Terry that both men and women secrete it’s in men stimulator testes to secrete more testosterone we’re here comes the weight loss that’s why women and men who have in a couple of done it together they say my husband’s lost more well we’re producing more testosterone and generally we have a higher metabolic effect with that regard and women it chances are they’ve gone through menopause ACG would have minimal effectiveness whereas if they’re still ovulating still having a menstrual cycle you have that effect in this but we do have to monkeys and monitor the hormones because what of all this and you’re producing too much estrogen and it in comparison the testosterone will you have that same weight loss and that’s why some women respond to it better than others so it’s a shotgun approach and in some regards it’ll work and others which have to monitor more closely my personal thought about particularly with men asking you this is that is are you looking to have more children Danone elder Chilean issue nailed because you’re you know if you’re just doing exogenous testosterone or or injecting or however the route is you can shut down like you said the testes over trying to reproduce try to have a kid candidate right so you need to be able to do to take the H. CG becomes critical there to boost your sperm count array increases your chances of fertility but if you’re not doing that right if you’re not interested in having more children just to do H. C. G. to boost your testosterone which we can correct by Thai trading your testosterone correct it doesn’t really make much sense now to add a whole nother agent another like you know they’re really likes keep it simple right let’s start slowing goes start low and go slow and you know that we can use to start from to just to do that if they’re not interested in and having children so and in some cases we’ve combined it because some men then let’s not take it for granted but there’s a vanity effective like I don’t want my testicles to shrink share and so then like maybe we combine a little bit of H. CG to maintain the testicular function but like you know earlier if let’s just keep it simple I’m a huge fan of keeping things simple and what what doses defined work well as a starting point for each CG so if it’s like border like symptomatic low testosterone but the levels are still technically normal and it’s just stress induced to maybe five hundred I use Monday to Friday or Monday Wednesday Friday it’s important to take a break with H. CG to allow that to Terry function to kick in and to rebound you don’t want to shut down your pituitary and how often do you recommend cycling like that you know is there some men little do it Monday Wednesday Friday for a long time and that is the cycle major like many cycles right and there’s some in the reserve Monday to Friday on a on a month off a month and just go that route so it’s kind of a patient specific as long as you’re giving a break a break you’re correct yeah yeah and then like you said for fertility it may be up to three thousand I use yeah so it just really depends on the state of that individual where it’s been titrated to right right right and finally I want to talk a little bit about any distinctions in your mind that you see between men and women when it comes to testosterone replacement is there anything you specifically want women to know or specifically want men to know that may be different there is generally a factor of ten two hundred yeah so if Vose than you’re getting with my doctor prescribed two hundred megs per mil of an injection generally you’re supposed to get twenty makes per Mille so if you all this and see that this is what I’m perfect and you do a quick search what have you and check us because we’re human we make mistakes they can get through the pharmacy you can accidentally be sent over an error and but we help each other we check each other but it happens so you know check that dosent don’t be scared to ask us side effects wise you’re you know if your purse and you getting lots of hair dark thickening here’s a female that’s a concern if you’re starting to all of us and have a deeper voice Sir testosterone can cause clitoral thickening rights if you’re playing into the vaginal area for sexual stimulation that can happen so if you’re experiencing those tell your doctor men if Wilson’s are gaining weight are you having a breast enlargement becoming apathetic mean which don’t care there’s a sign we could be converting over to estrogen or for not urinating properly our prostate could be coming in flames so tell your provider immediately so you just off the top of the head excellent yeah those are and what one practical question the point that you note noted that was important for me is that the concentrations are very different for men and women so you have a two hundred milligrams per ML concentration is subpoenaed for a gentleman but twenty milligrams per ML for women so significantly weaker but the reason why it’s important from a practical standpoint is because for example a man might be drawing up one ML for an injection but then you have a woman drawing up point one five zero so we fuse the high concentration just drying up the correct volume is going to be really difficult so now they’re getting varying doses from we can you don’t know how to titrate it so you it’s important to go down to a lower cost right they Sir drop one and L. two right that’s because that’s where it’s and called on the play yeah and we’re human too I’ve worked with some advanced medical specialists that have accidentally instead of taking point two five two two point five it happens and it’s you know it’s the important thing is that we catch it early enough fix it and move on to to learn from it but yeah that’s what company comes into play with to really isolating down the what’s the best mode of administrating the medication excellent anything else you wanna say Andy about testosterone do you want to maybe join a couple more committees on here

definitely yeah I know this is been great as my what mother would say you can talk for days this little have you accidentally and I appreciate that Dr Andy Ruiz thank you so much from Stonegate pharmacies will definitely have him back I’d like to thank founding media for hosting us thanks so much guys and we’ll see you next much yep the doctor talk podcast team includes me Dr redeem producer Mariah gossip an audio engineer Jake Wallace thank you to everyone attending media for your support the apple a day doc talk is available on iTunes stitcher Spotify or wherever you get your podcasts you can follow me on Instagram at green D. N. N. D. spelled R. A. N. D. E. M. D. or check out the link to my YouTube channel and website in the show notes thanks for listening