Erectile Dysfunction: The Warning Signs You Shouldn’t Ignore
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Coming up on this episode of The Doctor's Pharmacy. People's sex lives are not over at age, you know, 50, 60 or 70. There are men that come to me wanting to have prescriptions for Viagra at age 70. And I always tell them, I'm not giving it to you unless I get a written note from your wife. That's not going to go well.

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Hi, I'm Dr. Mark Hyman, a practicing physician and proponent of systems medicine, a framework to help you understand the why or the root cause of your symptoms. Welcome to The Doctors' Pharmacy. Every week, I bring on interesting guests to discuss the latest topics in the field of functional medicine and do a deep dive on how these topics pertain to your health. In today's episode, I have some interesting discussions with other experts in the field. So let's just jump right in. An estimated 30 million American men are affected by ED. Now,

People don't like to talk about this, and it's uncomfortable to talk about sex. It's kind of a taboo. But you have to talk about it because it's a significant issue that impacts so many aspects of people's lives.

Now, your physical health and sexual health are totally connected. Obesity, for example, is independently linked to erectile dysfunction. People have what we call a dad bod. You know, it's becoming normalized among young men where you kind of become a little pudgy around the middle. It's not normal. People with a high body mass index or who are overweight tend to have lower testosterone. I'm going to explain why that is and how you can reverse that.

Also, your emotional health and well-being are tied to your sexual function. People are stressed, you know, have more trouble with sex. Quality relationships and intimacy also plays a big role. And it's so common. We're going to talk about how common this problem is. In the Massachusetts Male Aging Study, ED was the most common sexual health problem. In 1995, it affected about 150 million men worldwide. And that's projected to reach 300 million next year.

The prevalence, in other words, the number of people in the population, men, obviously, who have this, is about 52% of men between ages of 40 to 70. That's a lot of guys. And what does it mean? Well, erectile dysfunction or ED means the inability to have or maintain an erection. Now, as you get older, it's more common. 40% of men are affected at age 40. 70% of men are affected at age 70.

A recent study published in the Journal of Sexual Medicine found that one out of every four men under the age of 40 is affected by ED. Now, that's shocking. You're talking about guys under 40, and that's about 25% of men under 40. There's also a strong relationship between testosterone, and particularly testosterone deficiency, and erectile dysfunction.

And it was shocking, and I see this in my practice, and it kind of blows me away, honestly. Young guys have very low testosterone. I mean, what you'd see sometimes I see in a 90-year-old, I see in a 20- or 30-year-old.

And about 30% of men age 40 to 79, according to the American Journal of Medicine article, experience low testosterone. Now researchers show an increased prevalence is associated with aging, that's common, but it's also associated with other diseases that are causing the erectile dysfunction. It's not just the penis that's the problem, it's the rest of your biology and your body that's not operating properly. So obesity, diabetes, high blood pressure,

are all clues that something's awry with your hormones, your metabolic health, and likely soon with your sexual health.

In fact, there's a phenomenon that's called andropause or male menopause, which is sort of a gradual decline in testosterone after the age of 30, about 1% to 1.5% drop in testosterone a year. Now, that doesn't mean it's a norm or it has to be. I mean, I have a guy who's like 62 who's got a testosterone of like 900, which is what you'd see in a healthy young 20-year-old or 18-year-old rearing to go all the time. And I promise you, he's rearing to go all the time.

It doesn't mean it's normal, right? It means it's common. It doesn't mean it's normal. Normal just means the average in a population. So it's quote normal, but it's not optimal. And so you have to understand how you want to get to optimal ranges by addressing the root causes of the problem. And there are a lot of ways you can naturally increase testosterone. Now there's a strong relationship between low testosterone and erectile dysfunction.

And the reason is that low testosterone is a clue for other problems. It's a clue that you have poor metabolic health. And it's so common. And I've talked about this so many times on podcasts, but 93% of Americans have poor metabolic health. And that is what leads to erectile dysfunction. I'm going to explain exactly how. We're getting into the science. And by the way, all the references, everything I'm saying is in the show notes. You can go dive deep. You can click through, read the articles yourself.

But it's a sort of scary picture in America now with increasing obesity, diabetes, and poor metabolic health. But this leads to what we call endothelial dysfunction. Now, what the heck is that?

Your endothelium is a lining of your blood vessels and the health of your blood vessels determines your sexual health and your cardiovascular health and your cognitive health and pretty much everything. In fact, that's one of the problems with COVID and with long COVID, which we've talked about, is this massive damage to the lining of our blood vessels. And that is what happens with COVID that drives so many of the pathologies. Now, men who have low testosterone are

are 38% more likely to die of a cardiovascular attack. That's like a heart attack or stroke. Now the question is why? Why do we see low testosterone? Well it has to do with what we call insulin resistance. Now I've talked about this for almost, God, scary now, say 30 years. It is something I've paid a lot of attention to. I've written many books on this.

Insulin resistance is the scourge of the modern world. Like TB was everywhere before, and it wasn't even as prevalent as insulin resistance. We're talking about 90% of Americans having some poor metabolic function, and that's some degree of insulin resistance, somewhere on the spectrum from optimal metabolic health, blood sugar regulation, insulin sensitivity, to a slow decline in insulin sensitivity, more insulin resistance, prediabetes, type 2 diabetes. It's all a spectrum.

And this leads to low libido or low sexual desire, low desire for sex, for masturbation. It's influenced by low testosterone. And basically, I'll give you the punchline here. But as your belly grows bigger, your testosterone gets lower. Big belly, low testosterone.

Why do you have a big belly? Because you deposit fat or VAT, visceral adipose tissue. And this visceral adipose tissue is a, excuse me, my French here, a storm of hormonal and inflammatory chaos. Essentially,

It causes an increase in what we call adipocytokines, and we'll talk about why inflammation plays a big role in messing up hormones, particularly testosterone. And it also causes an increase in estrogen for men, lower testosterone, and that leads to sexual dysfunction. So it's a big issue. And so this low sexual desire, low sexual function is influenced by this low testosterone, but it can be influenced by other things like stress, anxiety, and many other chronic diseases.

Now, a 2019 study of more than 12,000 45-year-old men found that about one in 20 reported low sexual desire, which is a lot when you think about 45-year-old guys. They should be still where they're going to go. Now, some desire for sex drops naturally with age, but it doesn't go away even in your 60s, 70s, or 80s. I mean, Mick Jagger had a kid at 75. Picasso had a kid. This was in the pre-Viagra era at 80 years old. So it's not impossible to keep going for a long time.

Now, what's the problem with our conventional approach to dealing with erectile dysfunction? It's not just as simple as giving people Viagra or Cialis.

It's really about taking a deep dive into the why, what's the cause. Now, often your hormones are not tested. It's amazing how many people go to the doctor and never get their hormones tested. Don't get testosterone, free testosterone, estrogen, FSH, LH, all the important biomarkers that are critical to understand what's going on with your hormonal health.

Also, doctors don't test for insulin resistance. I was recently on a conference call with some of the top scientists and doctors at Quest Laboratories Diagnostics, which is one of the biggest testing laboratories in the country, probably the biggest.

And I said, how many doctors are testing for insulin, fasting insulin? And they're like, well, it's pretty low. Maybe 1% of our lab tests are for fasting insulin that are ordered by doctors. Now, this should be a standard test that everybody gets as part of their annual checkup. It is the most important test to determine your longevity, your risk of heart attacks, cancer, stroke, dementia. It's so critical. The other test that they almost never look at

is what we call lipoprotein fractionation. I've talked about this on other podcasts. We'll link to those in terms of how to look at your lipids. But the cholesterol test that doctors do now is really so outdated. It's like, you know, looking at

things, you know, with a, you know, like, I mean, listen to your heart with a stethoscope instead of looking at it with an echocardiogram or an MRI. You know, it's kind of old-fashioned and it doesn't, it gives you some indication of what's happening, but it's really not the gold standard. And I asked, again, I asked these experts in cardiovascular diagnostics at Quest, I said, well, what percent of tests out there are for

the lipoprotein fractionation, which means the quality of the cholesterol, the particle number, the particle size, which gives you a much better indication of your insulin resistance and your risk factors. And I said, what percent of your tests are for this 21st century cholesterol panel?

And they're like 1% or less than 1%. And so that means 99% of people are not getting the right cholesterol test, which prevents them from really understand what's going on with their metabolic health. Now these tests, hormone tests, insulin, lipoprotein fractionation, A1C, many, many other things, we do test at Function Health. Now I'm a co-founder of Function Health. I'm the chief medical officer there.

And I believe that people should have access to their data and it's very empowering to know what's going on. We found all sorts of things. We've had over 25,000 members to date at the recording of this podcast. We've had over 3 million biomarkers tested and you can get over 110 biomarkers for

Less than $500 and you get testing twice a year and you can track what's going on. You can see changes based on your interventions, lifestyle, diet, supplements, and then actually be empowered with the right information and knowledge and education about what to do about these numbers. Anyway, back to the topic at hand. The other thing is most doctors don't really deal with lifestyle, you know, weight, weight

Diet, exercise, sleep, it's considered soft medicine. But the truth is, it is the most important thing in determining your risk factor and your health. And what do they do if you come in complaining of erectile dysfunction? Well, they give you the little blue pill. You know, that was a blockbuster. That was an accident. That pill was actually designed to treat high blood pressure, but it had a side effect that a lot of the people in the study noticed.

And they liked the side effect. And so the drug company got very smart. They were like, well, this is a lousy blood pressure pill, but it's a great pill for erectile dysfunction. And before that, it was tough for guys. They were vacuum pumps or you could have a penile implant. There was sometimes revascularization. You can do a transurethral kind of

thing called Muse. We used to recommend it's like pretty scary. You put a little pellet in the end of your penis. It's painful. There's injections which you can use that work, but they're painful. But when Viagra hit the scene in 1998, within six months of approval, there were over 5.3 million prescriptions written. And then the prescriptions have just tripled in the last decade. So there are a lot of other drugs, Cialis, Levitra, Stendra. They work for different reasons.

reasons and different people, different ways, but they're not bad to use. In fact, they can be helpful. They may be protective against Alzheimer's I read recently. So they increase blood flow, they increase circulation, they increase nitric oxide. We're going to talk about all that. And those are not bad things.

But more and more people are actually using this. Even younger people are getting it for off-label use. They secretly take it. They're embarrassed. They have performance anxiety. Maybe they have erectile dysfunction when they're younger. But let's talk about how these drugs work and how –

What is the physiology of actually having an erection? When you have sexual arousal, it causes the release of nitric oxide, which is a good thing in those cells that we call that line your blood vessels called the endothelial cells and they're in your penis. And so basically you get increased blood flow because it helps to activate something called guanylate cyclase, an enzyme. You don't remember it. Promise no test on this. And that leads to an increase in something called C-GMP.

Now, that particular thing causes the relaxation of smooth muscle cells, or it causes your muscles to relax, and that leads to the dilation of the blood vessels in your penis, and that increases blood flow, and that leads to an erection. And then it gets trapped inside the penis in the corpus cavernosum, which then, you know, maintain the erection and have fun. Now, after you ejaculate, there's an enzyme called...

PDE5 or phosphodiesterase type 5 and that degrades the CGMP. So a thing that keeps your erection going. Now that causes the smooth muscles to contract again and that reduces blood flow to the penis and that ends the erection.

Now, how Viagra works, Sildenafil, Encialis, Dadafinil, how they work is they inhibit this PDE5. They inhibit 5-phosphodiesterase, which is this enzyme that degrades CGMP. Now, that prolongs the effect of this particular compound, CGMP, keeps the blood vessels constricted in your penis, and it helps maintain the erection process.

for longer, which is fun and great and it's no problem. But side effects are common about over one in 100 people. You get mild headaches, dizziness, flushing, congestion, and sinus. Basically having sex, you're congested, runny nose and have a headache. Well, it's not so much fun. It can cause back aches, muscle pain.

Sometimes it can cause low blood pressure because it was designed for a blood pressure pill. It can rarely cause a painful erection to last a long time, like over four hours, and that's called pre-opism. And that can damage your penis, and it can cause all the heart issues. Rarely it can cause vision or hearing loss, but that's very rare. Now, if you're taking drugs like nitrate drugs, if you have angina, you have heart disease, if you have liver issues, you don't want to take them.

So they're not bad, but let's talk about maybe getting to the root cause, which is exactly what functional medicine is about. It's not about treating the symptoms. It's about the cause. So how do we get to the root cause? We have to really understand the full picture. And

And so we have to look at diagnostics. And I think it's really important to do a proper testing so you understand what's happening with your biology. And that's really why we've created Function Health, why I'm the co-founder and chief medical officer, because all the tests that I'm going to mention right now are all available at functionhealth.com and you can sign up. You can just get in there and get your test done. And there's a wait list, but we can get you off the wait list if you use the code DrHyman. Now,

The first thing you want to know is something called sex hormone binding globulin or SHBG. Now, this is important because it regulates the amount of free hormone, free testosterone. It's a protein made by the liver. It binds to testosterone and estrogen, and it basically makes them inactive. So it's sort of like a reservoir of extra hormones when you need them.

Also, albumin can bind to estrogen and testosterone, but not as well. And that's something that's normally in your blood. Now, when you have insulin resistance, high insulin, the liver suppresses the sex hormone binding log. And that leads to potentially more free testosterone. And that can kind of screw up normal hormone balance. And we often see an increase in prostate cancer in the large prostates in guys who have insulin resistance and big bellies. And that's a concern.

Inflammation, on the other hand, can also increase sex hormone binding globulin. So why does that matter? If there's inflammation, you get higher binding globulin. It means you get less free testosterone. And that's what matters. That's what does the job.

And so when you have less free testosterone from any source of inflammation, you can end up in trouble. So sometimes guys, even with insulin resistance, tend to have the high sex hormone binding globulin because of the belly fat, which is basically a factory of inflammatory molecules. Now, what does testosterone do? Well, it increases your sex drive or libido. It is involved in the production of red blood cells, which can sometimes be an issue if you're taking testosterone.

uh it is involved in sperm production mood so makes you happy or if you take too much you can make angry motivation so it's very important for motivation in men and women and by the way women have a lot of testosterone too it's really critical to build lean muscle mass which we'll talk about why that's important for sexual function it helps energy or cognition recovery from you know exercise or injury uh and it improves insulin sensitivity so it's good

Now, free testosterone is the active kind. It's not bound to the sex hormone binding globulin. It's the active form of testosterone, and it's not less than 2% of the total amount. Now, the optimal range, and these are all going to be in the show notes. You have to memorize them now, but you can check it out in the show notes. The optimal range is over 30 picograms per deciliter.

Now, you want to look also at the total and the free. So you want to look at both. Now, if you look at the total testosterone, the ranges are kind of screwy because, you know, how we develop reference ranges in America is based on the average or, quote, normal in a population. So if you're a Martian, you land in America, it's, quote, normal to be overweight because 75% are overweight. It doesn't mean it's optimal.

So the ranges that we see are not the really optimal levels, but you see ranges of 200 or 300 nanograms per deciliter. But the range should really be over 500. And you have to look at the combination of free and total, but it can be up to a thousand or more. And I think it's...

important to sort of look at what the symptoms are, what the person's overall health is, and look at the free and total, and you get a sense of how much is going on there. Now, even if your total can be normal, you can still have issues of low testosterone because your sex hormone binding lag is high. In other words, there's not enough free testosterone. So I see that very often in my patients. Also, the other hormone that guys have, which you probably may not know,

is estrogen or particularly estradiol. Now, men and women have estrogen and it has a lot of important functions. It does affect the libido, it affects erectile dysfunction, sperm production. It's also important for bone health, for brain function, and also for nitric oxide production. You don't want it too high or too low. And often guys who have big bellies have basically something called aromatase in their fat

which turns testosterone into estrogen. You don't want that. You don't want testosterone turning into estrogen. It's not nice. The other hormone you want to look at is the pituitary hormones and the hypothalamic hormones. Your pituitary hormones are really important. We call LH and FSH.

luteinizing hormone and follicle stimulating hormone now it's kind of a weird thing because follicle stimulating hormone sounds like it's for women's follicles that produce eggs but it's also active in men so in men um the way this works is your hypothalamus which is kind of way in the top of your brain it's kind of the master control center creates a hormone called gonadotropin releasing hormones so gonadotropins essentially are

the hormones that make gonadal hormones. So it's like stimulates the pituitary to produce the gonadotropic hormones, which are hormones that stimulate the testicles or the ovaries, which may be the case in women, to produce more hormones.

So LH, our luteinizing hormone, which again, it's kind of a weird name because it basically luteal phase of the menstrual cycle. It's named after women's hormones, but it really affects men too. So LH affects cells in the testicles called the lydic cells. Now these cells produce testosterone. So higher LH will increase testosterone.

FSH affects different cells in the testicles called the Sertoli cells, and they lead to sperm production. So LH, testosterone, FSH, sperm.

Really important and as important as fertility what's going on with somebody it's really important You may not know what's going on and you might have low testosterone But you could have a pituitary tumor for some reason so you got to check all these things also We look at prolactin another hormone. We check with function health again Not usually checked prolactin is another pituitary hormone that is involved in many things Including lactation. That's what I call it prolactin

prolactin, but it can be high in certain benign tumors that grow in the pituitary, which are not that uncommon. And the treatment usually is surgery. Sometimes there's drugs that can treat it.

We also need to look at inflammation and we look at something called HSCRP or high sensitivity C-reactive protein. Inflammation is such an important factor in our overall health and aging and longevity. High inflammation is a root cause of sexual dysfunction, whatever's causing it. Now, many things can cause it, including our diet. That's the number one cause, really sugar, starch, processed foods, all that's driving inflammation, our gut microbiome, environmental chemicals, heavy metals, toxins.

There's also endocrine disrupting hormones, which are really concerning to me. And I see a change in the population in the birth rates of men and women. We see changes in fertility. We're going to talk about that on another podcast. And I think a lot of it has to do with these forever chemicals that are petrochemicals that are in the environment that don't go away.

to have dioxin and PCBs and DDT, they're still around. And then we have other plastics and other pesticides and herbicides. These are highly dangerous and they're toxic at very small levels. So, no, you're like, I'm so out. I'm not getting that much this or that. But but you are, you really are of your lifetime. And then they've done fat biopsies of people and they found pretty much every human is a toxic waste. And we probably wouldn't be safe to eat if we were food.

Other hormones are important as well. Leptin, again, something we check on Function Health that mostly doctors don't check, but leptin is the appetite suppressing hormone. But sometimes when you have insulin resistance, you also get leptin resistance. So you see high levels of leptin and that leads to low testosterone and suppressed LH.

So that's concerning. In one study in the Journal of Clinical Endocrinology, they looked at three groups of men and they found that those with higher leptin levels, mostly due to leptin resistance, had a higher body mass index, so they were heavier, and they had lower levels of testosterone. So it's an important thing to check. Adiponectin, another important hormone, it's an anti-diabetic hormone, it's an anti-inflammatory hormone, it prevents heartburn.

heart disease, and it's often low in insulin resistance and inflammation, obesity. So you want to check adiponectin again, and we check that as part of our panel with Function Health. Again, it's not usually checked, but it's important because if it's high, it's good, and if it's low, it's bad. We also check your fasting insulin and hemoglobin A1C because insulin resistance is really, I would say, the

majority of the causes of erectile dysfunction as we get older. And it leads to, like I said, low testosterone, higher belly fat, more estrogen, abnormal cholesterol, more inflammation, low sex drive. It's just not a good thing. And your insulin, you really want between two and five. Now, most reference ranges are 15, again, because the average American is unhealthy and overweight. So

The reference range is wrong, basically is what I'm saying. So in functionality, talking about what are the current reference ranges and what are the optimum ranges. Also, you want to look at stress hormones like cortisol and DHA. And you also look at...

cardiovascular testing and not just a regular cholesterol panel, as I mentioned, but looking at what we call lipoprotein fractionation. And this really looks at cardiovascular risk, insulin resistance, really important. And I think if you don't look at the right cholesterol panel, you're basically just living in the 20th century and not the 21st century in terms of cardiovascular health.

a thyroid also really important and we have to look at thyroid properly not just the way doctors do it on their traditional panel or the tsh you have to look at the tsh the free t3 free t4 even thyroid antibodies which we all check on function health and and they're really important because thyroid function if it's low will cause a low libido low sex drive a low low mood and it may be as simple as taking thyroid and also will influence sex hormone binding alignment now none of these tests

Tests are hard to get or expensive, but unfortunately your doctor's probably not doing most of them or doing them properly. So that's why, again, I co-founded Function Health and encourage you to check out your own tests so you can see what's going on and be empowered with your own health data and be the CEO of your own health.

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My dad works in B2B marketing. He came by my school for career day and said he was a big ROAS man. Then he told everyone how much he loved calculating his return on ad spend.

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that come to me wanting to have prescriptions for Viagra at age 70. And I always tell them, I'm not giving it to you unless I get a written note from your wife. That's not going to go well. Actually, yesterday, I was doing a consult with a patient who was 87 years old. Yeah. Who's still having sex with his wife.

I plan on it. Yeah. I'm going at least to 100. I don't know. It's only getting better as time goes on, so why stop? That's exactly right. So this is a very common problem. From a traditional medicine point of view, there really wasn't much of an approach to this beforehand. We had some really coarse and crude treatments. Talk about what the traditional approach to erectile dysfunction has been, other than

the Viagra, Cialis, and Levitra category of drugs, which now are pretty widely prescribed and do work and help people. Yeah. So, you know, prior to Viagra, there were some fairly primitive approaches to it, like vacuum pumps and revascularization, because vascular issues, endothelial dysfunction is a key part of what causes erectile dysfunction.

So in English you're basically saying that you get hardening of the arteries in your penis which makes it not so hard. Right. And so but that hardening of the arteries not only reduces blood flow but there's this endothelial dysfunction and it's in the endothelial cells that nitrous oxide has its effect. So what are endothelial cells? Endothelial cells are the cells that are lining the blood vessels of the, that are inside the penis. So throughout your entire body you've got these lining of all your blood vessels.

And it's a very active lining. It does all kinds of things, including regulate the dilation and the blood flow and lots of other things, inflammation. And nitric oxide is a key regulator of that. Very key. And that's what goes wrong. And what are the reasons why that men tend to get this decreased blood flow in the penis that leads to these erectile dysfunction?

There's multiple reasons, but before we go on to that, I think probably is a good idea, let me just review quickly, because we're going to talk about nitrous oxide. We're going to talk about why Viagra works and other drugs like it. Essentially, what happens is that

you have the release of nitrous oxide. Nitric oxide. Nitrous oxide. Nitrous oxide is laughing gas. I'm just going to call it NO. Okay, NO. So you release the NO, and then NO has its action on the endothelial cells inside the blood vessels of the penis. It also acts on the corpus cavernosum muscles. And so you get this simultaneous release

relaxation of those muscles so blood can flow in. Those are the big muscles of the penis so that when they're full of blood, they actually start the erection and maintain the erection. And then you have the small blood vessels. Nitrous oxide acts on those at the same time and causes those to constrict. So the blood that flows into the cavernous muscles then stays there as these small veins constrict. And that

basically starts the erection and maintains the erection. And what happens is, and that's called tumescence. Then you have detumescence when after the ejaculation, the penis relaxes. And that's when

5-phosphodiesterase breaks down the compound that was responsible for causing that relaxation and constriction. And when that compound breaks down, the small blood vessels relax and the penis relaxes and becomes flaccid.

it's the 5-phosphodiesterase that gets inhibited by Viagra. Yes. So this is just a little lesson to everybody listening. That's how it works. Viagra blocks the 5-phosphodiesterase, allows this... So basically it increases blood flow and...

makes the erection stay longer and longer. - Because you don't get the breakdown of this thing called cyclic GMP. So that doesn't break down, that maintains the constriction of the small blood vessels. You can maintain, actually obtain an erection and sustain an erection for a longer period of time. - It's a good thing you don't have to remember all those chemical names when you're having sex, 'cause that would not go very far. - No, it wouldn't. But that's what's going on. And so then what can affect, what are the things that affect that? So metabolic syndrome.

So when you're thinking about people with ED, see all the blue pill does is fix that end problem.

It fixes that, let's just make sure we get the erection and we maintain it. But there's reasons why we get there. We get there because of stress and its impact on that very, very sensitive neurovascular problem. That neurovascular, and it's not a problem, that neurovascular symphony that has to occur for you to have your erection, ejaculation. Yeah.

Metabolic syndrome... That's prediabetes. Which is prediabetes, which includes, you know, to make that diagnosis, you have to have obesity, dyslipidemia, which is just abnormal... Cholesterol. Cholesterol, triglycerides, HDLs. You have to have hypertension. And one of the things is insulin resistance.

And so insulin resistance is connected to endothelial dysfunction. When those endothelial cells aren't working, then the NO, the nitrous oxide, is not gonna have an impact and you're not gonna be able to start that erection. So what do you treat? You can give the person Viagra, but since metabolic syndrome has so many of the impacts on their overall health and their health span and lifespan, it'd be better to fix that.

- Wait, okay, so let me translate that because that was really good. I think here's what's going on. Basically, people eating lots of sugar and starch and crap in their diet get prediabetes, which goes along with high triglycerides, low HDL, high blood pressure, belly fat, the whole thing. - Exactly.

And when you have this problem, which by the way affects every other American, and if you take out the kids, it's probably more than half the adults, right? So we've got 75% overweight, 88% metabolic, man healthy in this country. Most of those people have some degree of insulin resistance. And what you're saying is when you have this phenomena going on in your body, it damages the ability to

of the lining of the arteries to function properly so you can't get blood flow in your organs, not just in your penis, but in your heart and in your brain, which is why insulin resistance causes heart attacks and strokes

And also dementia. So this is all connected. And in fact, the first sign of heart disease is probably having trouble getting an erection. I was about to say, you're worried about your erection, but you know what? You better be worried about your heart and your brain because they're the ones that are really the target of what's going on. Absolutely.

Absolutely, and I think people don't realize that. It's not just a local problem, it's just a systemic problem. Absolutely. And so... That's one of the points I really hoped we'd make today, because as important as erections are, it's getting those root causes that impact your overall health, and then the cherry on top of the pie is great erections. Yeah, and I think most people don't realize that our whole system is connected, and that's what's so different about functional medicine is that it's looking at the whole system.

Most people don't think of your diet when you think about having sexual dysfunction, but that's the first thing we think about. We do think about stress, for sure, that plays a role. There's alcohol. One of the roles that alcohol plays is that when you're drinking alcohol, that itself is going to impact that endothelial function during the time of your use. And you're going to maybe, that night,

not have an erection. Here's what happens. You can stop drinking and say, okay, that will fix it. But there's something that happened. You're going to have a psychogenic response. It's called performance anxiety. And for some men, once they have a failure,

it multiplies itself. They get performance anxiety and it becomes a psychogenic problem. And there's a vast majority of men who have erectile dysfunction actually have a performance anxiety or psychogenic cause. So basically just if it doesn't work once, you're going to be afraid it doesn't work every time and that's going to make the whole thing worse. Yeah. Yeah. So that's, that's a hard mental thing to fix. But the, um,

The fascinating thing to me is that the phenomena around seeing this as a systemic metabolic vascular issue is so important. And there's a lot of ways to address it that we're going to get into. And of course, there's a lot of ways to also address erectile dysfunction that are up and coming, that are quite new, just far beyond Viagra, which we're going to talk about. I'm excited to talk about those things.

But even in traditional medicine, you've got the vacuum pump, which is pre-viagra, where you put a little ring around the base of your penis and you basically put a tube around your penis and you basically vacuum it all the blood in, which doesn't sound like fun to me. And there's penile implants, which can work. There's alprostadil, which is an injection or something that goes inside the urethra of the penis that can help. That's a prostaglandin.

And there's revascularization, which is something I would love you to talk a little bit about. So revascularization is essentially you're having, as we talked about, hardening of the arteries. And it's two ways that can be done. Just like you have angioplasty or stents placed in the heart, the same thing can be done for the penis. And that's one possibility. So it's basically like angioplasty for your penis? Yeah.

Wow, that's incredible. And... Again, these are very interesting responses to the problem. And we're going to go through other possibilities. As you said, we're going to talk about stem cells and platelet-rich plasma. I always like to go back to the idea that, yeah, you can be revascularized, but why get there in the first place? Exactly, right. Yeah.

It's like you get a stent, but you got to fix your... All of these things actually work. I mean, I've had patients of mine use a vacuum pump. I don't know how they do it. It works, doc. I love it. I've had people get penile implants. It works, doc. I love it. And they're pressing their testicle and they're getting their erection. And that's how the pump works. The pump is inside one testicle and you start pressing on it and it gives you your erection and it works. I've had men use the injections. They feel like 18 years old again.

But they all have diabetes, hypertension, metabolic syndrome, and I can't get them to get to that underlying cause. So almost sometimes when I'm not let them get their erections. - Well, let's talk about testosterone because there's this whole conversation out there about male menopause or andropause and this whole syndrome of low T or low testosterone.

And I think part of it's gone to the extreme and there's a lot of bodybuilders who use testosterone and I think can be used inappropriately. But what I want you to talk about is why do we see the drop in testosterone

as men age? Because I think this is really important. There are natural ways to raise testosterone. There are ways that we are living that lower testosterone. So let's get into talking about that because if you fix testosterone, a lot of things get better. A lot of things do get better. Erections may or may not get better. Testosterone can definitely have an impact on erectile dysfunction. It impacts the five phosphodiesterase we talked about earlier, and it also can have an impact on nitric oxide.

And that can result in improved erections. Now you ask me, why do we see this drop off in testosterone? Well, there's this natural drop off of testosterone as men age. So after the age of 30, you're losing about 1% per year. And over time, that's going to drop you pretty low.

But that's not going to do it all by itself. Now, I've seen many older guys with raging high testosterone levels. Here's the older guys that don't have raging testosterone. Those are the guys that have sleep apnea, alcohol over, they drink too much alcohol, they have diabetes, they haven't learned how to manage their stress. Did I mention sleep apnea? You did. Yeah, I did.

But that's a very important one. And so those are things that as you age, begin to impact your body's ability to make testosterone. Yeah. So I just want to emphasize something you said there. It's so important. You said diabetes, but this whole pre-diabetes insulin resistance thing is the biggest reason. So here's the deal. The bigger your belly, the lower your testosterone. And the smaller your

The more belly fat you have, the lower your testosterone is. And people don't understand that. And then you mentioned alcohol. And the reason alcohol is such a problem is that it increases...

a hormone converter called aromatase, which is an enzyme that converts testosterone into estrogen, which is why you see guys who are drinking lots of beer and alcohol have man boobs and have big bellies and lose the hair on their chest and lose the hair on their legs so they become more like women and they have very high estrogen levels.

So people are shocked to find that out. So you basically become like a woman the more alcohol you drink. Absolutely. And I think those two things are really important for guys to understand because if you are struggling with erectile dysfunction, it's a big deal for people and they don't understand that it's directly related to what they're eating. Now, in addition to the fact that eating starch and sugar will lower your testosterone, what are the things that actually might increase it from a dietary point of view? Mark, it

It goes back to one of the books you wrote. It's called Eat Fat, Get Thin. So now I'm going to tell you this. The name of the book can now be, the one that I'll write will be Eat Fat, Get Hard. Oh, gosh. This is getting to be a racy podcast. We've got to put explicit warnings on this one. You know what, Nate?

They should have known getting us together this was going to happen. So, yes, fat. Because fat actually, we've talked about this before, has cholesterol in it. Cholesterol is not a bad guy. Cholesterol is a really important foundational molecule for building hormones and one of them is testosterone. So eating good healthy fat is going to allow you to have that precursor molecule to maintain high levels of testosterone as long as you're doing everything else right. Sleeping well, managing stress,

and limiting your alcohol use. The next topic I want to get into is people's often challenging subject for people to talk about, which is sexual dysfunction. And it's a pretty big problem across the board for men and women. And it's something people really don't talk about that much. We had the little blue pill, Viagra, everybody was happy, but

There's more to it than that. And I want to talk about some of the approaches you have. But first, can you share some of the scope of this problem and who it affects and what kinds of things you are doing to help people solve this issue? Because, you know, I have this patient who's like 75. And I mean, all she does is talk about sex and all her partners. So people can stay sexually active for a long time. I have 80-year-old patients who are like, I want to keep...

and being engaged and I think we often say, "Oh, I'm 50, I'm over it." You know, I had met another guy who was like 58 and he's like, "I'm done." You know, like I'm like, "Wait a minute, you're done?" It's like, you don't have to be done. And so, I think what are you finding in terms of the scope of the problem and what are the kinds of things that are really working?

Scope of the problem is significant, and it just is not in the older population. We're seeing problems age 30, age 30, 40, 50, men and women. 80% of erections in men is vasculogenic. It's due to blood flow.

20% is hormones so a lot of the a lot of the younger patients come in and say listen my testosterone must be low because I can't get an erection but that's not the case it's it's other things that are involved vessels blood vessel flow blood flow is a big problem now why do people have lack of blood flow yeah it turns out that you know atherosclerosis starts at age five you can start having plaque yeah and the first sign of of

Erectile dysfunction is endothelial dysfunction. The endothelium is the inside lining of blood vessels. We have 60,000 miles of blood vessels in our body. - How many miles in your penis? - Well, so it turns out that it's one organ, not multiple organs, the endothelial system.

So, people often ask, you know, as a cardiologist, why are you dealing with erectile dysfunction? Because the first sign of endothelial dysfunction is erectile dysfunction. The first presentation that someone has a blockage in an artery is lack of early morning erections or erectile dysfunction. Yeah. So, when we see that... Can be a sign of heart disease, diabetes, right? Absolutely. Diabetes is a big thing. Hypertension is a big problem.

Alcohol is a huge problem. When you have alcohol, you have an acute inflammatory reaction in the blood vessel wall. But the most that we see is sugar. - Sugar. - Sugar is extremely inflammatory. If you have a Coca-Cola, within-- - So basically the donut or a Coke or an erection, you gotta choose, right? - Within two hours, right, within two hours of having sugar, we can actually measure in the urine an inflammatory mediator

We can actually measure your blood vessel by looking at endothelial function testing to see that it's vasoconstricted after sugar. Sugar could precipitate a heart attack. There was a good video. - So basically you don't have dessert if you wanna have sex, is that the idea? - You gotta pick what you want. So sugar's a big problem, but what we're finding out is blood flow is huge and like you said, to see the diseases or what we're eating and that can affect us a lot. - I want people to really get that.

Dr. Shapiro just said is that sugar is one of the biggest causes of sexual dysfunction.

Well, sugar is the biggest cause of inflammation inside the blood vessel lining, which is a big factor. Which is a reducer of blood flow. It's all about blood flow. So what are some of the things that we can do to increase blood flow? A technology that I recently started using about a year ago is called GainsWave. GainsWave uses low intensity, extra corporeal shockwave therapy, and it basically can optimize men's health. It can optimize performance. What it does is it creates a small injury. Injury then...

says a message to the brain. The brain releases mediators, mesenchymal stem cells, to go to that site and increase blood flow by causing what's called angiogenesis. So actually the Gaines Wave treatment, which has been very popular lately, and it's available all over the US. We do it in New York City and my Westchester location, but it's involved everywhere, but it's for two things. It basically helps increase blood flow.

And it does that by angiogenesis. And angiogenesis means growing new blood vessels.

Correct. So anytime you have an injury, your body is trying to repair that injury. And our natural repair mechanism is stem cells. So you have a cut on your finger or a shave. You're shaving and you have a cut. What happens in two days? It's healed. Why does it heal so fast? We have a self-repairing mechanism. So this low intensity shockwave therapy, Gaines Wave, basically gives you this small injury

uh and we're all familiar with with shock wave therapy for lithotripsy right lithotripsy is higher intensity for kidney stones so this is low intensity so the gains wave therapy basically works by in

angiogenesis, new blood vessel growth and growth factors, bringing new growth factors to the area. Usually we do a treatment once a week or twice a week. It's about six sessions. It doesn't hurt. It's not painful. It's non-surgical. It's not invasive. Patients see results, you know, significant. We're getting great responses. And usually we do six treatments or 12. Some people have Peyronie's disease, which is a plaque, a fibrous plaque, an injury to the penis. This has been...

curing it in patients. And these are young patients that we're seeing, you know, 30s and 40s, some 50s and 60s. But, you know, we're seeing some great results with Gaines Wave Therapy. It's, you know... So when you get like six or 12 treatments, is it a temporary result or does it affect your longer-lasting? We're seeing results lasting up to two years. It's sort of like having a cardiac bypass in a sense, right? You get new vessels.

Well, yeah, not exactly. I mean, that's the mechanism of it. Let's say you exercised your whole life compared to someone who was sedentary their whole life and you both had a heart attack. From the books, remember some of these studies, the person who exercises is gonna have a smaller heart attack. The person who doesn't exercise will have a larger heart attack. What does exercise do? Grows new blood vessels.

So, you know, if someone who exercises a lot, who has some blood vessel growth, but, you know, sort of like is having a lot of ED issues because they changed their diet, they have some inflammation and their blood vessels are kind of like constricted. This will help knock off some of the calcium inside the vessel wall. It'll increase dilation of blood flow, bring in more growth factors. And basically... So it's like regenerative medicine for the penis, basically. Yeah.

Correct and it may allow you to throw away your fire gray or sialis, right? So so, you know sialis and viagra work locally on the penis by phosphodiesterase Pd5, you know

Receptor inhibitors and what this is doing is you're inhibiting constriction So you're dilating but there's other side effects with some of these medications it reduces blood flow to the eye Sometimes you can have increased visual changes You can have increased reflux by reducing lower soft gel sphincter pressure in the esophagus and

I mean, you know, sometimes they're great, like Cialis 5 milligrams daily is great for people with BPH because it reduces the pressure on the prostate and allows you to urinate better. That's been a help with a lot of patients, but sometimes combination therapies help. Like we mentioned exosomes before, so now we're taking exosomes and we're doing what's called an XX shot or an XY shot.

And basically what that does-- - We call it a P-shot, is that it? - So I actually trained with Dr. Ronells and learned PRP and did a lot of PRP, the P-shot, the O-shot, which helps a lot of women and men, but that's with their own blood. We spin it down and we re-inject it back into them. So we're getting some growth factors. But if you compare PRP with some of the new therapy exosomes, you know, exosomes, you're talking about a tremendous increase in growth factors that basically

make the result so much more powerful. So, you know, I'm doing some PRP now, not as much. I'm doing a lot more exosomes. I think exosomes will be the future. I know a lot of the... Those are injected directly into the penis or... Yeah, so, you know... Sexual organs. You go right into the penis. You numb up the area. Sometimes you can do a nerve block. It's no pain at all.

and it takes about 15 minutes and the response is significant. Patients with prostate cancer who have decreased sensitivity, who got radiation, who now can't get an erection, now suddenly can get an erection after an exosome injection. - That's amazing. So how is Gaines Wave different from other treatments for erectile dysfunction or performance enhancing drugs?

well because the gains wave is the only therapy that's that's basically using low intensity shockwave therapy it's not pharmacologic it's not invasive it's drug free non-invasive surgery free we improves blood flow gives a better erection quality you have harder erections more full erections sexual performance is improved and actually a lot of patients will come who are younger who want to increase performance

They have good erections, but they want performance. They want to be able to last longer. So they come in for performance issues, not ED issues. And then we have maintenance. Once the patient goes through their six or 12 sessions, they'll come back once a season and get a maintenance treatment.

But the combination thing of exosomes, PRP or... Diet, exercise, all of that. And gains weight, exercise, so important. Diet, eating less sugar, keeping those vessels dilated, very important. And we're seeing it's a safe procedure too. Everyone's concerned about surgery. I used to send a lot of patients for bypass, coronary artery bypass, graft surgery.

And if you need it, you get it. But I mean, right now we're trying to do multi-vessel stenting. And I can speak for hours on just cardiology and traditional disease management. But I mean, here we're talking about more natural ways to stay younger and healthier and live longer.

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