In episode #142 Dr. Pamela Wartian Smith, MD is interviewed by Dr. Jill Carnahan about optimizing male hormones. In this video you will learn all you need to know about male hormones, testosterone levels, environmental affects and how to optimize your hormones for peak performance.
- Which lifestyle factors are contributing to decreased testosterone production in men
- Why environmental toxins play a role in low levels of testosterone in young men
- How testosterone has become the new addiction and why too much may be just as bad as too little
The Guest – Dr. Pamela Wartian Smith, MD
Pamela Wartian Smith, M.D., MPH, MS spent her first twenty years of practice as an emergency room physician with the Detroit Medical Center in a level 1 trauma center and then 28-years as an Anti-Aging Functional Medicine specialist. She is a diplomat of the Board of the American Academy of Anti-Aging Physicians and is an internationally known speaker and author on the subject of Anti-Aging/Precision Medicine. She also holds a Master’s in Public Health Degree along with a master’s degree in Metabolic and Nutritional Medicine. Dr. Smith is in private practice and is the senior partner for The Center For Precision Medicine with offices in Michigan and Florida. She has been featured on CNN, PBS, and many other television networks, has been interviewed in numerous consumer magazines and has hosted two of her own radio shows. Dr. Smith was one of the featured physicians on the PBS series “The Embrace of Aging” as well as the on-line medical series “Awakening from Alzheimer’s” and “Regain Your Brain”. Dr. Pamela Smith is the founder of The Fellowship in Anti-Aging, Regenerative, and Functional Medicine and is the past co-director of the master’s program in Metabolic and Nutritional Medicine at The Morsani College of Medicine, University of South Florida. She is the author of eleven best- selling books. Her book: “What You Must Know About Vitamins, Minerals, Herbs, and So Much More” was published 2020. Her best seller, “Max Your Immunity,” was released in late 2021. Her newest book: What You Must Know About Women’s Hormones, 2 nd was released in the spring. Her book, Maximize Your Male Hormones, has just been released.
Dr. Jill Carnahan is Your Functional Medicine Expert® dually board certified in Family Medicine for ten years and in Integrative Holistic Medicine since 2015. She is the Medical Director of Flatiron Functional Medicine, a widely sought-after practice with a broad range of clinical services including functional medical protocols, nutritional consultations, chiropractic therapy, naturopathic medicine, acupuncture, and massage therapy. As a survivor of breast cancer, Crohn’s disease, and toxic mold illness she brings a unique perspective to treating patients in the midst of complex and chronic illness. Her clinic specializes in searching for the underlying triggers that contribute to illness through cutting-edge lab testing and tailoring the intervention to specific needs.
A popular inspirational speaker and prolific writer, she shares her knowledge of hope, health, and healing live on stage and through newsletters, articles, books, and social media posts! People relate to Dr. Jill’s science-backed opinions delivered with authenticity, love and humor. She is known for inspiring her audience to thrive even in the midst of difficulties.
Featured in Shape Magazine, Parade, Forbes, MindBodyGreen, First for Women, Townsend Newsletter, and The Huffington Post as well as seen on NBC News and Health segments with Joan Lunden, Dr. Jill is a media must-have. Her YouTube channel and podcast features live interviews with the healthcare world’s most respected names.
Dr. Jill 0:12
Well, hello everyone, and welcome to another episode of Dr. Jill Live! I am so excited to have a returning guest, Dr. Pam Smith, today. We're going to talk about her new book and optimizing male hormones. I don't talk a lot about this topic, but I think it's so relevant. I know from the feedback we got from already posting the poster that this is coming up and that a lot of you are going to be listening, coming back to listen, or sharing this with your partners or spouses. We're in for a real treat today. Before I do that, I just want to remind you that you can listen to all of our other episodes on YouTube, iTunes, Stitcher, or wherever you listen to podcasts. I would love for you to subscribe on YouTube or give us a review. Those help to get more viewers, so we thank you for that.
Dr. Jill 0:55
Today, let me introduce Pam. I have talked to Dr. Smith before, so you've seen her before. But today I'm super excited about the conversation. Dr. Pamela Wartian Smith spent her first 20 years of practice as an emergency room physician in the Detroit Medical Center at a level I trauma center and then [another] 28 years as an anti-aging functional medicine specialist. She's a diplomat on the Board of the American Academy of Anti-Aging Physicians and is an internationally-known speaker and author on the subject of anti-aging precision medicine. Pam, how many books have you written now?
Dr. Pamela Wartian Smith 1:26
Twelve. The 12th one will be coming out this year.
Dr. Jill 1:30
Yes, it's so exciting. As I said, you are a pro at this, and they are always such best sellers. I want to go on. I'm going to make sure and include the rest of the bio, but I want to get to our interview. I will note the names of your books. She's been featured on the PBS series The Embrace of Aging as well as the online medical series Awakening from Alzheimer's and Regain Your Brain. She's the founder of the Fellowship in Anti-Aging, Regenerative, and Functional Medicine and the past co-director of the master's program in Metabolic and Nutritional Medicine. She has done so much, and again, [she has] 12 books. The new book we're talking about is Maximize Your Male Hormones. It was just released, and, Dr. Smith, it sold out, right?
Dr. Pamela Wartian Smith 2:09
It did. It sold out in eight hours, which I could not believe because I actually had a hard time convincing my publisher for many years that men would read a book on hormones. And so we had a big discussion again, and I said: “Well, if men don't read it, the women in their lives will. So let's go for it,” and it sold out in eight hours. So it's just being released again in the next printing.
Dr. Jill 2:34
Amazing. Yes, we said today, right? It's available, and it'll be available when this podcast is on, so you can get your copy. We'll be sure and include links to all of that, but it's called Maximizing Your Male Hormones. And it's such a relevant topic because, like you, I'm sure that in practice we are seeing more and more effects. And we'll talk about all the details of male hormones being sabotaged by our environment—by the chemicals, by the diet, by the lifestyle. So, I'm seeing at least younger and younger men who are struggling with hormone levels. Many of them don't even know it. They just know they don't feel well, right? So let's talk about the big landscape first. Why is this such a big deal now versus 50 or 100 years ago? What are we seeing that's leading to more and more men struggling with optimal hormone levels?
Dr. Pamela Wartian Smith 3:12
Well, in July, it will be my 45th year of practice. And you're right—it is totally different. When I was a young doctor, we never saw men with testosterone levels that were low before the ages of 42 and 45. Now we're seeing men in their 30s and sometimes even in their 20s with low testosterone levels, and there's a myriad of reasons why that happened. Certainly, toxins are a big one. Stress is a huge one. We've talked before about the stereogenic pathway. But pregnenolone, the hormone of memory, makes cortisol—your hormone of stress—but it preferentially makes it. Pregnenolone also makes DHEA, testosterone, and estrogens. But if you're stressed long-term, the body doesn't make a lot of testosterone. So in today's world, honestly, who is not stressed? In my personal practice, I have one patient who has normal cortisol—one!
Dr. Jill 4:13
Wow. Wow. And I totally relate because it's the same with me. It's either off-the-charts high or, nowadays, after years and years and years and years of off-the-charts high, sometimes it's just flatline—low. So we have these both extremes. And what you were just saying is that our body has to have cortisol to survive, so it will do everything in its power to keep that flood of precursors going toward cortisol because we can't survive without it. And the innocent bystanders are testosterone in both men and women, but today we're talking about men. So stress is a big one. Stress is probably the biggest factor. What other factors do you see contributing to the decline of male hormones?
Dr. Pamela Wartian Smith 4:50
Part of it is that some men have actually been using testosterone or its precursors at too young an age, so their body doesn't want to make any as they age. In fact, honestly, the newest addiction now is testosterone in men. It has become an addiction. People start it too early. They take too much. The levels are really, really high. And people do not realize the side effects if you use testosterone when you don't need it or if you have too high of a dose.
Dr. Jill 5:27
So let's talk about that. Let's take an average. Say a 32-year-old male comes in. His testosterone is a little suboptimal, and he asks me or you: “Doc, my testosterone is low. I'd like to get a prescription.” What would you caution them? What would you say? How would you tell them about the potential dangers of too much? Tell us a little bit about how we would look at this kind of person. And it could be, I would say, anywhere from 25 to 45; that's kind of the range we're talking about, right? The younger men before they hit the male testosterone decline.
Dr. Pamela Wartian Smith 5:57
Well, really, we try not to give testosterone to men before the age of 42. There are other prescriptions we can give them if they need to boost testosterone, depending on the state in which they live. There's Clomid [and] hCG. There are other choices [other] than testosterone itself, because if you give too much testosterone, it doesn't stay testosterone. It converts to E1 and E2, which are estrogens, and it converts to dihydrotestosterone. Men do need estrogen. Commonly, they're surprised. They need it for memory. They need it for bone structure. However, too much estrogen increases the risk of heart disease and prostate cancer. And, of course, I know a lot of people know about dihydrotestosterone and hair loss. That's a big one that most people think about. But if you give too much testosterone, DHT will go up. You can end up with too much testosterone and with blood clots. You can end up with a pulmonary embolus, a heart attack, [or a] stroke. The consequences are actually really large, and unfortunately, it can lead to your demise.
Dr. Jill 7:10
So I want to talk about the symptoms of low or high testosterone. But let's first go down this path because I think this is important and very poorly understood by the average person. Testosterone with blood clots—you and I know why [that happens]. But many people listening are like, “Ooh, I didn't know about this.” Tell us a little bit about how it affects the blood cells and how they might even see it on the lab [results], and then why that would lead to a clot, like a stroke or heart attack or something.
Dr. Pamela Wartian Smith 7:32
Well, when we order a test, when we look at giving hormones to men, we always order a complete blood count. That's a blood study that's done at any major lab. The reason we do that is [because] we want to look at the red blood cells, the hemoglobin, and the hematocrit. We want to see where it's at. If you give too much testosterone, then all three of those can actually elevate. When they go up, then clotting can occur. A lot of doctors that are not trained in this field unfortunately give too much testosterone, and then they tell the patient, “Oh, just go donate a unit of blood.” If you've been given too much testosterone, that is the answer. But it's not the answer every single month to go donate a unit of blood. The answer is to use less. We usually use testosterone transdermally, meaning on the skin. We used to use it more as an injection or a shot. Very early on, we would do it twice a month. Then we started using smaller doses twice a week. But if you use an injection, it's certainly not wrong. But the first day, it's probably a little high. The next day is probably the perfect dose. And the third day is probably a little too low. When you put testosterone on the skin, it really mimics what the body does because a male's testosterone actually changes four to six times a day. And we want it to be natural. That really is God's plan for life—to mimic the perfection that God has designed for us.
Dr. Pamela Wartian Smith 9:09
So the other study that was really startling was not just about blood clots, but when it comes to IM testosterone versus [testosterone] on the skin, it has to do with erectile dysfunction. And this really gets a man's attention. If you put testosterone on the skin, it helps with ED—erectile dysfunction—83% of the time. If you use it as an injection, [it] only [works] 53% of the time. ED is an issue with a lot of men, for many reasons. But choosing testosterone on the skin—it doesn't take a lot. Men only make four to six milligrams of testosterone at their peak age at 25. So on the skin, we never give more than 50 milligrams of testosterone. There's honestly no need to do that.
Dr. Jill 10:00
That makes sense. And you're giving it on the skin daily or intermittently?
Dr. Pamela Wartian Smith 10:05
We are giving it on the skin daily. At least at this point, we don't give men a hormonal holiday like we do menopausal women. But it's not just sexual interest. Yes, that's huge, but testosterone [also] lowers cholesterol, blood sugar, [and] blood pressure. It's muscle mass. It's energy. It's bone structure. [There are] so many things that it does. Yes, sexual interest gets everybody's attention, but certainly lowering your cholesterol and maintaining memory should as well.
Dr. Jill 10:42
Yes. I love that because that's the big thing. And I'm talking to men and women all the time—or women and their spouses or whatever—about this because I say testosterone for men is so important. Like you said, all those things and diabetes and all these [other things]. Let's go back to symptoms. Say someone listening is like, “Well, I haven't tested.” First of all, let's talk about: What do you do to test? And then second, what would be someone presenting with low testosterone? What symptoms would they have? Like you said, it's not just libido; it's so much bigger than that. What would a male who presented with low testosterone maybe feel like?
Dr. Pamela Wartian Smith 11:14
For a lot of men, the first symptom they get is actually fatigue, not erectile dysfunction. In fact, if a man has erectile dysfunction, that means there's clogging of the arteries in that part of the body. So we immediately send them to a cardiologist to see if there's clogging in the vessels of the heart and the carotids in the neck. So ED equals heart disease. So we back up a step, and we want to really go back and see: Is their erectile dysfunction because there's clogging or because there is not enough testosterone, etc.? Everything that I'm talking about is in my book, Maximizing Your Male Hormones. The references are online. You get a code for it. And they're updated, so you get updated references all the time. That way, people can stay current. Another really important thing is diabetes. In fact, the American Endocrinology Society has come out now with an article [saying] that if a man has diabetes and it's new onset, meaning newly diagnosed, the first thing they should do is have their testosterone measured.
Dr. jill 12:25
Excellent. It makes so much sense to you and me, but people listening might be like, “Really?” So yes, it causes that adiposity around the organs, which is visceral. If you don't have testosterone, you gain more weight in those visceral areas. And those are very predictive of the risk of metabolic syndrome, obesity, [and] diabetes. So it's really, really important. I love that you're saying that. Erectile function, libido—all these things the males care about [are concerns], but it's even bigger as far as longevity. So we talked about young people and why maybe they should be more careful. Say you do have someone who is very appropriate, maybe with a testosterone level below 200. What would you say [is the] cutoff for too low? I might treat them a little sooner than 200, but what would your cutoff be?
Dr. Pamela Wartian Smith 13:07
Well, that's a great question on testing. Honestly, usually, I do salivary testing and not blood [testing]. It's because I'm going to do saliva testing later on. If the hormones are put on the skin, they do not show up in the blood. There are three trials to show that. One [is] by David Zava, an Israeli study, and then the one we're going to publish, where we actually looked at it in both men and women—hormones on the skin, any of the hormones, any age of the patient—and none of the hormones showed up on the skin if you look at blood testing. So if you're going to put testosterone on the skin, you do have to do salivary testing. You actually spit; it's not a swab. People think [it's] like a COVID test, but no, it's not like that. You actually spit it into the tube. Plus, when we measure cortisol, the stress hormone, there are six clinical trials showing that cortisol does have to be measured by saliva. That is the most accurate method. Some people purport that you can measure [testosterone] in urine. It's important to do a urine test. It's really important because we want to see how testosterone is broken down and what kind of estrogens it makes because if it makes the wrong ones, there's an increase in prostate cancer. But we don't dose off of urine, and the reason is [that] it's a metabolite. It's actually a breakdown product; it's not the level of the hormone itself. And how I, you, or everybody else in the audience today would break things down is very, very different in relation to weight, age, genetics, medications people are on, and a myriad of other things.
Dr. Jill [pre-recording] 14:53
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Dr. Jill 15:49
That's so great to talk about because if you go to the average primary doctor, they're maybe not going to even know that saliva or urine testing exists [for that]. So if they are getting blood tests, maybe at the beginning, they're typically going to get [tested for levels of] estradiol, DHEAS, free and total testosterone, cortisol AM, and then maybe progesterone or pregnenolone. You can get those in the blood [test]. Would you say that's okay for a start if someone is not on therapy, if their doctor's doing that as a screen to kind of see where they're at, and then you'd follow [up] with salivary [testing]?
Dr. Pamela Wartian Smith 16:19
You could do that, but then you're comparing apples and oranges because later on, you're going to do saliva. You should also do E1—estrone. You need to do both of the estrogens. Men make E3 as well, but we look at E1 and E2. And again, we don't want their estrogen to be high.
Dr. Jill 16:37
Yes. Now, my cut-off on blood would be around 50, but what about saliva? Is there a cut-off or number or just a range or anything that would be—
Dr. Pamela Wartian Smith 16:46
Dead center of normal.
Dr. Jill 16:47
Okay. Got it. Perfect.
Dr. Pamela Wartian Smith 16:49
Dead center of normal.
Dr. Jill 16:50
You can mention labs. Who is the lab that you like for salivary testing?
Dr. Pamela Wartian Smith 16:53
Actually, right there, I was talking about ZRT. They are a great lab. There are other labs that do this testing as well. There's Genova. There's Doctor's Data. There is Access Medical. There are a number of labs, all of which are very much CLIA-approved and have the latest technology.
Dr. Jill 17:14
Fantastic. So you can ask your doctor for these. And they're not super expensive. I mean, a few hundred dollars [for] most of them. They're not off the charts crazy expensive. Does that sound right to you?
Dr. Pamela Wartian Smith 17:25
It is. The only exception to that is pregnanolone, the hormone of memory. And pregnanolone is really important because not only is it the hormone of memory and it makes the other hormones, but people make assumptions. I will be 69 in July, and you would assume at this age that I have low pregnenolone, but honestly, I don't. My pregnenolone [level] is still very normal. It has to be 50 to maintain memory. My last one was a few months ago; it was 58. So do I take pregnanolone? No. This is why we measure—because we don't want to give people hormones they don't need.
Dr. Jill 18:02
Right. So that brings me to a point that I think a lot of people don't know: Cholesterol is at the top of this whole cascade, right? So let's talk about men who are on cholesterol-lowering medications. What does that do to the hormones? And again, I'm not against it. There's a very appropriate use of statin medications, so please hear me. But there are some men who are on those that get their cholesterol so low that it can affect hormones. Can you talk about that connection?
Dr. Pamela Wartian Smith 18:25
Absolutely. Unfortunately, cardiologists, honestly, usually just look at the heart and don't look at the whole body. That's really why you should have an anti-aging functional medicine prescriber see [what's going on] because they're the people that have studied all of this. They've done a fellowship in this field so that they understand the range of all this. Let me tell you a true story of one of my patients: A 42-year-old male dentist came in and said the following: “You know what? I think I'm going to quit practicing.” At that time, I was 10 years older than him, and I said: “Well, I don't feel like quitting practicing. Why?” He goes, “Well, my dexterity is not there. My memory is not there. I don't have energy. I just don't see as well. I just don't feel as good.” Then he handed me his lab [results] from his primary care doctor, and there was the answer. His doctor had literally written a smiley face by the total cholesterol [result] of 104 because it sounds great when it comes to the heart. But total cholesterol has to be 140 to make pregnenolone [and] the other hormones.
Dr. Pamela Wartian Smith 19:40
I'm not anti-statin drugs. Like you, I do prescribe statin drugs. They're great anti-inflammatories. There are many ways to lower cholesterol. But you don't want to get it too low. And honestly, we took him off of the statin drug because he really didn't need it. We gave him a little berberine, and that was plenty to keep his cholesterol total at about 160. In nine months, he felt great, and he's still practicing now because his memory came back [along with] his dexterity. People don't realize that men have testosterone receptors in their eyes. Testosterone helps prevent macular degeneration, glaucoma, [and] cataracts. They have testosterone receptors in their hearts. They have testosterone receptors on their colon, so testosterone being optimal helps prevent colon cancer. It's many, many things.
Dr. Jill 20:34
Amazing. Hold up your book again, because I want people to be sure and grab a copy of this. The one thing Dr. Smith does so well is make things simple and easy. You've got lists, [and] you've got protocols. The way you do things in your book—your writing, your teaching—makes it simple. And you've always done a great job at simplifying, even for those of us other doctors who are learning from you. The other thing that you do is include references. I love that. So anyone who is maybe going to their doctor and their doctor's not quite so sure can find those references. And you even said there's an online link so that it's continuously updated, right?
Dr. Pamela Wartian Smith 21:05
It is continuously updated. We started doing that with the last two books, and it honestly worked out really well.
Dr. Jill 21:12
Because by the time it goes to the publisher, we know it's out of date, right?—it's changed so quickly. So that's even a better way to do that. Amazing. Let's talk really quickly to the women who have men in their lives who may have low testosterone, because often the people listening are women. My biggest audience is women aged 30 to 60. So if you're a woman listening and you think maybe your husband or your partner or your dad or even your son has testosterone issues, what would you tell them as far as getting them in to get checked? Give us a little spiel for the women out there.
Dr. Pamela Wartian Smith 21:48
Absolutely. First of all, I would suggest this book is for women as well. It is just as much for women as it is for men because it's important to understand how the male body works and [how the] female body works. So that's the first thing. Number two, they really should see a prescriber who is fellowship-trained in the field. In the book, there's a link to the American Academy of Anti-Aging Physicians, so you can go right on that link and find a prescriber in your area—someone that literally has done an entire fellowship in this field; it is really important. Also in the book, we go through other things. We talk about cholesterol. But we talk not just about testosterone and DHEA, which also lowers cholesterol, but we actually do give people some tips on other ways to lower cholesterol and triglycerides and [their] risk for heart disease, etc.
Dr. Jill 22:46
Fantastic. So it's the whole male. Everything you want to know about your husband, as far as the medical facts and the testosterone and everything. That's fantastic because, [with] male hormones, like you said, [there is] way more [involved]. Do you go into insulin and some of the metabolic stuff just briefly as well?
Dr. Pamela Wartian Smith 22:59
Absolutely. Absolutely, because it's just as important. It's part of the reason why we want men to be hormonally balanced.
Dr. Jill 23:07
Yes. So [there are] two other things that I think are important. DHEA—people may or may not know what that is. Tell us about: What is DHEA? When would you use DHEA for men?
Dr. Pamela Wartian Smith 23:17
Well, pregnanolone makes DHEA, which makes estrogen and testosterone. DHEA can go down if you're stressed because it's a companion hormone to cortisol. Both are made in the adrenal glands that sit above the kidneys. DHEA also declines with age, so it's very variable. For men, we give them straight DHEA. For women, it's a little bit different. If women have high testosterone, are acne-prone, or [have] normal testosterone, then we give them a special kind of DHEA called keto so [that] it doesn't make a lot of testosterone. But in men, we give them DHEA, which makes estrogen and testosterone—both.
Dr. Jill 24:02
Beautiful. And then the last thing is—I know your book is for men, but because we have women listening—women can have low testosterone too. So is this something that you check? Do you ever replace this in women as well? And how would that look? Would that also be transdermal? Give us just a little bit of a snapshot on women.
Dr. Pamela Wartian Smith 24:18
Absolutely. In my book, What You Must Know About Women's Hormones, Second Edition, which came out eight months ago and is double the size of the previous edition from 2010—
Dr. Jill 24:31
We're way more complex, right?
Dr. Pamela Wartian Smith 24:33
Women are much more complex. Absolutely. And there's the misnomer now with testosterone. Again, testosterone really is the newest addiction. People think, “Oh, every woman needs testosterone. It gives her sexual interest, it gives her energy.” But, if you actually look at the numbers, only one-fourth of women lose testosterone as they age. I'm one of those who did not. If I haven't lost it by now, I'm not going to. Mine is in the dead center of normal and will always stay there. If I use testosterone, then I would have an increased risk of heart disease and stroke. Also, blood sugar tends to climb. It's important that women… If they are low in testosterone, they need it. [It helps with] sexual interest, lowers cholesterol, [gives them] energy, [and] they need [it for] muscle mass. Women do need all of those things. But we don't want to give them testosterone if they don't need it.
Dr. Jill 25:29
Yes, absolutely. Dr. Smith, this has been so fun as always. Where can people get your books? Where's the best place to find you? Give us a little bit of [information on] where we can find [out] more about how to get the book. And you've got all your books, so we want to promote those. But this new book is on male hormones.
Dr. Pamela Wartian Smith 25:45
Absolutely. You can certainly go to Amazon and get my book, which is probably the best location for you to get it at the most cost-effective [price]. If you're going to buy it in bulk for all of your friends, people at your business, or family members, then you can go directly to [the] squareonepublishers[.com] website and get it from there. And then you can also go to DrSmith.com. [At] any of those locations, you can get a copy of the book.
Dr. Jill 26:11
Perfect. I will include all those links if you're listening or watching. Wherever you're at, you will have those links down below as well. Dr. Smith, and, my friend, thank you so much for today. Thank you for bringing your wisdom. Thank you for continuing to publish great information and for continuing to be an educator, not only of the public but of doctors like myself. We're very grateful for you.
Dr. Pamela Wartian Smith 26:32
Well, thank you so much for the interview today. And you are a blessing to me—very much.
* These statements have not been evaluated by the Food and Drug Administration. The product mentioned in this article are not intended to diagnose, treat, cure, or prevent any disease. The information in this article is not intended to replace any recommendations or relationship with your physician. Please review references sited at end of article for scientific support of any claims made.