Ryan Jones, MD (00:00)

All right, hello everyone in the Thrivelab community. How are you doing? My name is Dr. Jones. Welcome to TRT Talks where we deep dive into different topics affecting hormone health, longevity and performance. Today, we're unpacking a topic that affects millions of men. Still a bit taboo, although most of us have heard of it before, which is erectile dysfunction, an under-discussed topic, willingly or unwillingly by providers and patients. And I'm joined today by Dr. Patel. He's a leading expert in functional medicine and hormone optimization. And together, we're going to explore the different aspects of how this condition affects men, what we can do to treat it, and hopefully get you guys to some good solutions if possible and have some good  information out there. Dr. Patel, introduce yourself.

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Nayan Patel (00:40)

Absolutely, thank you for having me today. I am Dr. Nayan Patel, I'm the Chief Scientific Officer at Thrivelab and with Dr. Jones and myself, we've been working hand in hand concurrently for the last few years to bring in functional hormone replacement therapy to all of Thrivelab community and our goal is to basically help you with not just a symptoms evaluation and solutions but also to help with overarching wellness and longevity goals that people have today. 

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Ryan Jones, MD (01:06)

Absolutely, absolutely.

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Nayan Patel (01:14)

So I'm looking forward to this discussion because this is absolutely something that is something that I am very familiar with it. At the same time, I know there's a lot of questions around this ED that's been overwhelming. So thanks for having this today.

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Ryan Jones, MD (01:21)

Right, right. Oh, absolutely. And so just to start, I guess, with the basic definition of erectile dysfunction, it's basically an inability to maintain or sustain an erection long enough to complete the sexual act to a person's satisfaction, a patient or their partner's satisfaction. And it has been increasing in prevalence exponentially over the past two or three decades due to a variety of factors. Some of them being lifestyle, some of them being medication induced, some of them being social. But what I want to do first is kind of break the stigma and say that this is a problem that many men deal with and they shouldn't be afraid to talk to their health care providers about it because it affects their lives in many aspects emotionally to begin with. ED can lead to a loss of a sense of masculinity or maleness. It can affect relationships, relationship satisfaction, as it's been regularly scored in personal satisfaction surveys and happiness surveys between individuals and couples. And the stigma around it often delays treatment. And what we want to be here at Thrivelab is an open source and an open line of communication, not only to hear about the struggles that men may be dealing with in this arena, but also to offer effective solutions. And so I just want to normalize this conversation by saying it's commonplace, it's okay to discuss, we have an open ear and we're ready to do what we can to help out. A lot of times men express maybe shame, frustration when this comes up. Have you had any stories or any patient experiences about how it's affected their lives?

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Nayan Patel (02:43)

Well, the thing is that most of the people that I talked to, are what you just said earlier, they're not willing to discuss this situation at all. And what you said is absolutely correct. It's more than physical. There's an emotional side to ED as well. And so we talk about erectile dysfunction. That means it's just an issue about blood flow, but it's way more than that. The stories that I get to hear from all the medical team is basically male patients coming in asking for questions and more than likely we are diving deep into a bar and beyond just prescribing some products that are just increasing blood flow.

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Ryan Jones, MD (03:19)

And so kind of as a frontline health worker, work in both hormone health obviously here, but also in primary care and a couple of other healthcare settings. And I can say the most common scenario by which this topic is brought to me is at the end of a visit because of that stigma. Typically we talk about their diabetes. People are willing to be upfront about that. Their hypertension, they're willing to be upfront about that. And right after you kind of close the laptop and you're ready to end the visit, they kind of hit you with the Columbo. The one more thing, doc, I wanted to ask you about and that's typically where they start to open up a little bit about the subject. So I've learned as a healthcare provider to kind of fish a little bit for our patients, not just to wait on them to express the information to me, but to let them know in addition to their physical health and their mental health, the sexual health is also important to me. And that tends to open up the flow of conversation for them, give them an easy pass, an icebreaker to bring the topic up. And so as far as your understanding is Dr. Patel, what are some of the disease causes of erectile dysfunction that you may be aware of?

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Nayan Patel (04:17)

So, the most of the things that we are looking at right now is of course we look at the low testosterone levels, see if that's a learning factor or not. We're looking at vascular health for people, especially the endothelial dysfunctions. If there's any, we can help them fix that one. Medications, absolutely.

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An average person is not taking anywhere from six to eight different prescription drugs. And I see this every single day in my pharmacy as well, that people are taking more medication than they need to. And there's drug interactions that can lead to some reducing blood flow, chronic stress. I talk about oxidative stress and metabolic stress all the time. And it's a huge factor in this whole realm of longevity medicine especially for internal dysfunction and of course let's not forget the gut health. Gut health, inflammation leads to all kinds of stress issues, leads to hormone imbalances, leads to mental disorders and anxiety and mood swings, leads to all kinds of other physical changes inside your body. So I wish we could have one thing that's causing that, that's easy to fix it, but it requires a whole body approach and I'm glad that at Thrivelab we do look at whole body approach and try to find out the root cause analysis so that would be just not prescribing medications to you, but we're trying to find solutions for you.

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Ryan Jones, MD (05:32) 

Absolutely, and so dealing with some of those interventions that we take to improve erectile health and sexual function I typically like to approach it or explain to patients the very basic mechanisms by which erections occur. And it usually starts with what we all know is arousal, something that the individual finds stimulating or attractive triggers a cascade of things in the brain but one of the most important consequences of that is that one of the major signals nitric oxide is released, right? And that causes a secondary effect local down in the blood vessels to release something called cyclic GMP I believe. And that is the one that causes arterial side. So let me kind of back up just a little bit. To maintain a good erection, you want basically two things. One is a good amount of blood flow in and something kind of stopping the blood flow from going out or at the very least slowing it down. So I imagine trying to fill a bathtub, you want to turn the faucet on and you want to close the stopper. And so the cyclic GMP kind of triggers those effects to occur via causing vasodilation or an opening of the arteries, which brings blood flow in and also closes the vascular side causes a little bit of vasoconstriction on that end on the on the vein side to minimize the amount of blood flow that comes out.

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And so our medications and our treatment strategies when it comes to medications, although there many other factors, typically tend to target those two things, right? So one, you want stimulation or arousal if possible. And that's one of the early places where I see testosterone play a role, right? Which is frankly in libido. It increases, I think, your drive, your hunger, your vigor, your vitality, your desire for sex in general. And I think that lowers the threshold for what typically triggers stimulation or leads to arousal.

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That is one of many ways I believe testosterone contributes to overall sexual health. But on the back end, where the vascular side occurs, long-term use is certainly improved with good hormone optimization, but several lifestyle factors ahead of that play a role, and that includes diet, that includes your weight and your exercise program, and like you mentioned, gut health, which can affect a lot of downstream things.

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At Thrivelab, we take a kind of whole body approach to our patients. We don't want to just hear the story that you have it quickly prescribe you a pill because one, that may not work, but two, you may not get the optimal effect. You want a multi-system and whole body approach in order to optimize the outcomes for our patients, and that's what we do here at Thrivelab. So many of the traditional treatment target symptoms without asking the why. And the why can have a variety of contributors, and that's where it's our job to really dive into your history. Are you having metabolic derangements? Do you have certain disease conditions like diabetes, hypertension, that may be contributing? Are the medications you're on contributing to the ED? And I know you mentioned that. Are there a particular classes of medications that you've seen be more or less involved with erectile dysfunction?

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Nayan Patel (08:19)

Well, the main thing what we do first is we evaluate testosterone, make sure that that's optimized. But the thing is what we are looking for more importantly is are there any medications for diabetes or cholesterol that may be affecting the blood flow. Are there any medication that may be affecting the mood or the inability to experience joy? Anxiety medication, depression medications may also affect the libido as well as the internal dysfunction. The most important part for even for the environmental factors, we look at sleep quality. How is that? Is it increasing or reducing cortisol levels? Are they eating food that are high in sugars and carbs, is it driving inflammation? Are they eating a lot of ultra processed foods? And so all these things affects your overall well-being. Definitely, physically you can feel the effects of having issues with ED, but at the same time, mentally it's a lot more than just physical erection. Even moderate alcohol intake can cause, can reduce sexual performance. So all these things do play a role in their part. And so even though we may not have medication for every single thing for you, we certainly do want to prescribe ways that you can do at home at no cost to you to help yourself. When people come to us, they want something and I tell them a lot of times it's not what we give you, it's what we tell you to do at home at no cost. Sometimes doing less is actually working more for you. Eating less of the ultra-processed food, drinking less alcohol, having better sleep, all this, there are no cost to you but have a massive impact on your overall well-being.

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Ryan Jones, MD (10:05)

And that's awesome because that's exactly what we train our providers. That's exactly what we train our providers to interact with our patients to gather that detailed history that can suggest all the lifestyle modifications, all the medical interventions, the diet points, the environmental factors, the social factors that may be contributing to their ED and help them come up with a plan and a solution to get them feeling a little bit better. One, when a patient visits my clinic and this issue comes up, I generally want to them for trusting me enough to open up about such a sensitive and from there we kind of begin our overall plan. Like you said, assessing the hormone panel is a key function. If the testosterone is off or low, there's other hormone dysregulation. Let's look in that. That's not a quick fix, but that's a target area that typically yields high yield results. So that's one that we tend to focus on.

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Asking about other disease states, men who have a history of cardiovascular disease very commonly have issues with ED. The same process that leads to those conditions can affect the smaller vessels and the male genitals, which can lead to ED. And so we talk about the lifestyle modification factors that may be helping there. Blood pressure medications is another one. You think you're treating one thing and you're causing another problem. So sometimes there's an adjustment we have to make into which exact cocktail of medications you're taking to maximize the efficacy of both of those things. Like you said, neuromodulating medications, typically those that are aimed at psychiatric health, antidepressants, benzos, CNS depressants like benzos, I'm sorry, and alcohol those things can kind of bring your system down and can inhibit sexual function and also desire. So targeting those lifestyle factors matter significantly and well, that's certainly something that our healthcare providers are trained to address with our patients. And then so beyond that, there's sometimes saying, well, doc, we've kind of ran through those things, we've optimized those things. I still feel like I'm struggling a little bit. So what are some of the solutions that we're gonna actually work with? And so addition to hormone optimization, our company is able to provide some of the more traditional medications targeted at improving erectile function, Cialis and Viagra. And you being our resident pharmacist, can you give us any highlights about those two medications and what the differences may be?

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Nayan Patel (12:05)

I mean they're both the pd5 inhibitors that help increases the blood flow and I mean they're amazing products that has been proven tested for decades now it's not something that that has been just newly approved products we don't offer shots at this point because quite frankly the shots are done at the office, at the urologist office. And they're for more severe cases. These are for nerve ending issues. People with severe diabetes ends up taking the shots. And so if you need those kinds of service or products, we're trying to help people before they get to that stage. And that's our goal. If I can help, 80, 90 % of people will never end up in a urologist office to try and take a shot. And so we want to make sure that those medications that we provide you to increase the blood flow is going to be sufficient enough to do so. For example, some of the products, like for example, Tadalafil, which is the chemical name for Cialis, at a very low concentration has shown benefit impact on the prostate health itself. So having a low dose of Tadalafil on your regimen can actually impact your prostate health in the first place. So prescribing like five milligrams of Tadalafil is going to be sufficient to have a better prostate health. And like it or not, we are all guys, I'm a man and one day if I don't take care of my prostate it's going to get enlarged. And so I have to be very careful about those kinds of things and making sure that my diet does not have anything that's going to aggravate that prostate health. At the same time, can eat pumpkin seeds and things like that to reduce your DHT loads, that seems to be one of the culprits to increase prostate enlargement that can lead to ED as well. So having a diet, making sure that our nutritionists on staff are very educated enough to basically help you pick a diet that's going to be there to help you reduce that inflammation in the process itself. But at the same time, I want to make sure that people have ideas about long-term versus short-term successes, right? Short term you can take a pill and the job is done. The long term it's way more than involved than that one and requires a full on approach from dietary to nutrition to environmental factors, to overall well-being, your mental status, and every single thing. So even though you may be coming in for short-term results, or short-term solution, what we look for is always for long-term possibilities. And what can I do today that can have a long-lasting impact on your health and wellness? So that's the way I feel like it should be the right approach for anybody.

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Ryan Jones, MD (14:51)

Absolutely. And again, the in-depth approach there is a marker of the quality of care that we provide here. So to kind of not summarize, but to kind of go down my decision tree, typically in optimizing it at multiple levels, usually I always like to start at the level of the brain, right? Getting the libido up. That's one place where obviously hormone replacement is essential. If that is the deficit that one has and is markedly effective, if that's deficit that one has. One of the things that may be a little bit less spoken about regarding the libido and stimulation effect is as much as possible, right? And without judgment, I do ask my male patients who are struggling for this to save it for a real life, right? Which is kind of code speak for try to limit the situations in which arousal occurs to those at which you want the payoff to occur, right? With your spouse, with your partner in reality and try as much to avoid some of the, we should we say, online mechanisms of stimulation because that can contribute sometimes to not necessarily overuse but a blunting of the arousal system that can be self-defeating, right? And that can lead to a cycle of lower performance and then kind of depending more on those mechanisms for pleasure. So as much as possible, it's a bit of an uncomfortable conversation sometimes. But I asked my patients in addition to the hormone health that we provide to sometimes save it for in person if you can. And then kind of going downstairs from there, what are the local factors that may be contributing? Again, if they have disease states like diabetes, or even if they don't have diabetes, but their diet is just high in sugar, in processed foods, those are independent risk factors for erectile dysfunction. Getting those things in line will kind of help boost their sexual health as well. And then the medications that are targeted towards treating those conditions. A lot of times if you have already been affected by those conditions which impact your artery health, atherosclerosis, the one that leads primarily to heart attacks but also contributes to ED. Sometimes those men find themselves on nitrates, that is one of the major contraindications to being on those two medications that we mentioned earlier by trade names Cialis and Viagra. And so we'll have to kind of optimize some of our other mechanisms of improving sexual health in that regard. Making sure adequate blood flow is available in your body is prepared to do so. And that's where exercise comes in. Being able to shift blood to the places where it's needed is a critical function and very improved by a regular exercise program, be it weightlifting or cardiovascular health. Some guys who are weightlifters may notice that after they go to the gym and they do a couple reps of bench press or a shoulder press or whatnot, that their chest looks a little bigger, just a little shinier, just a little bit more well-defined, which is colloquially known as getting a pump. But it's a real effect. It's because blood has been shifted from other areas of the body to where it's needed and a good regular exercise program helps your body do that not only locally in those tissues, but in your overall health and your overall body functioning, which can lead to an improvement in erectile function. And then going from there to mitigate the things that healthcare may be contributing to that are exacerbating the problem like we discussed earlier, looking at the medications that they may be on that are contributing to the erectile dysfunction. Again, sometimes it's a matter of tapering them, adjusting them, stopping them, finding which medications work best. In the cases where those medications are a bit outside of our scope, we will communicate with primary care and other specialists to make sure that they are on the appropriate medications to treat whatever conditions they come to us with while we also work to optimize their sexual function. Other lifestyle modifications, illicit substances typically just don't help in many aspects but particularly in sexual health even those that are traditionally known to be stimulants can impact sexual health negatively and of course alcohol is one of the well-known both short-term use or acute use, should say, at the time if you happen to have a heavy volume of intake or long-time chronic use, both are associated with decreased sexual function. And then lastly, after that, we've kind of exhausted some of the healthcare aspects of it otherwise, finally deciding on what the appropriate treatment on is typically my go-to, giving our patients the two options. And going between those two, just to kind of circle back, the most commonly prescribed in addition to hormone optimization, being Viagra and Cialis, I'm sorry, Cialis. The side effects and the effects are similar, but their time course tends to be a little bit different. In short, Viagra tends to be a little bit shorter in duration and a little bit faster in onset. Cialis tends to be significantly longer in its duration of effectiveness. That's why it's colloquially known as the weekend pill to kind of where you want to take one and kind of be ready for that   spontaneous picture to know that whenever the moment arises, you want to be ready. Where with Viagra, it's typically more targeted that, you know, hey, this evening we're going to have a little bit of our fun, so I'm going to plan to take the pill a little bit earlier. But just giving, just asking the patient kind of what their sexual history is, what their pattern of behavior is, and finding out which one may be more less sorry efficacious for them and fits better to their lifestyle is also part of making the decision between which of those medications may be prescribed. Anything else to tail on on the medication side there.

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Nayan Patel (19:42)

Well, I have a different approach a little bit. Let me just do my approach because I'm more holistic. Even though I'm a pharmacist, I hate drugs. So I just want to make sure that people understand that part. I'm not a pill pusher by all means. And so while all these medications are great, let's not forget, let's start off with small, small things. Cut out the sugars, cut out the alcohol. Make sure your sleep patterns are better. There are so many apps out there that can help you put you to deep sleep and a theta sleep, right? I've used an app for myself, an eye patch over there so there's no lights getting in there, doesn't decrease your melatonin. Small, small things like these makes a big, big impact overall. And it's not just for erectile dysfunction, this is mainly just for longevity medicine in general, this is gonna help you. The one thing that has worked for me the most is daily gratitude. Just be thankful about things that you are because when your mind opens up to be grateful guess what the love pours in, the love pours in from your partner and from your spouses. Everything becomes so much fun and enjoyable. So it's more than the physical, it's also emotional. So I want to make sure people practice daily gratitudes on a regular basis because that's what has changed my life and for my patient's life as well. And then, eat a normal diet that is full of amino acids because that's going to build up your muscle mass more than anything else. If you're over the age of 40 or 50, I can guarantee you, I can give you all the testosterone in the world, but you're not going to grow the muscle mass as much as what amino acids is going to trigger the muscle growth itself. So they both go hand in hand and they both work to help you with your ED issues. I want to make sure people understand that there's no one magic pill that's going to solve the problem. The magic pill is Cialis that can solve, but it's temporarily. If you're looking for long lasting effects, you have to do all those things in conjunction. So I just want make sure people understand this, that even though we like to prescribe medications to you, you have to do more things at home on your own to have long lasting results.

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Ryan Jones, MD (21:49)

Excellent and that's one of the reasons it's important to keep a long-lasting and engaged relationship with your provider and schedule those visits because over time these things can improve and if you start to stray off course it's important to have a sounding board and someone who can guide you in the right direction on maintaining those various aspects and I love that you highlighted the emotional component of this because of course they come in in a situation that is obviously not emotionally favorable. None of the emotions typically associated with ED are positive. There's a lot of shame and guilt. But a lot of times I hear a story where it's literally that they feel passionate about their partner and they want to express that love as much as they feel it, right? And on the back end, having an effective regimen that boosts your sexual health gives you a lot of that reward that you've been looking for. You're able to connect on a little bit more intimate basis, right? And patient satisfaction and couple satisfaction scores after having an appropriate lifestyle modification, medication intervention if needed, and hormone adjustment therapy show that both the partner and the patient themselves both experience an increase in happiness and overall relationship satisfaction. So I think there's definitely light at the end of the tunnel there. You just got to give the right people a chance and I believe that's us here at Thrivelab.

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Nayan Patel (22:56)

So I just want to make sure that I do make sure that people understand that even though we would love to have all the behavioral modifications and lifestyle adjustments to be made, we still do prescribe testosterone replacement therapy, both injectables, topicals, and whatever your body needs. We do monitor on regular basis. So we do real-time monitoring via blood tests, urine tests, saliva tests, whatever is necessary by the providers. We will do a comprehensive approach for that. We will prescribe you whatever is necessary for you take control of your body. But once all those things are done, we also make sure that you have a full approach about other modalities that you can do at home on your own to have a better outcome and better results for yourself.

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Ryan Jones, MD (23:38)

Absolutely. We look forward to our patients experiencing an improvement in their relationships, their work life, their self-esteem. We provide personalized care with remote access. We have options for injectable, topical, and oral medications both on the hormone and erectile dysfunction side. Dietitians, which can help on some of the lifestyle modification and all of our providers, are of course well versed in adequate and appropriate exercise regimen and some of the other lifestyle modification factors that may be necessary to achieve the best health for our patients both mentally physically, and sexually.

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Okay, so I just want to kind of summarize here by acknowledging the importance of our providers in listening to the symptoms and to our patients, to noticing those symptoms that may be arising in them, which is low libido, fatigue, and erectile dysfunction. And I know that's the direct topic of what we're talking about today, but that may also be associated with changes in your hormone health. And so we feel we're an appropriate mechanism to reach out for that. We have a free hormone health assessment that you can do online. It's a self-assessment to kind of let us know some of the things that you may be dealing with. Give our provider a little bit of a pregame prior to the first meeting so that they can come with a pre-tailored plan for you that is augmented with a discussion in the detailed history you guys get via that one-on-one connection during your telehealth visit with your provider. And I don't want you guys to feel like you have to live a compromised life. We don't want you to just be okay, we want you to be the best possible version of yourself in all aspects, mentally, physically, spiritually, emotionally, sexually, and others. And so we're happy to provide that care at Thrivelab the best we can. So please give us a holler if you will.

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