Testosterone Replacement Therapy:
Expert Insights with Dr. Rak

In this informative episode of the Skin Report, Dr. Rak, a lifestyle medicine physician based in San Francisco, joins Dr. Sethi to discuss the intricacies of testosterone replacement therapy (TRT) for both men and women. Dr. Rak shares insights from his personal health journey and transformation through lifestyle changes, emphasizing the potential of diet and exercise over hormonal therapies. This episode offers a deep dive into how lifestyle factors influence testosterone levels and overall health, providing listeners with a comprehensive understanding of when and how TRT should be considered as part of a broader health management strategy.

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Dr. Simran Sethi:
Welcome, everyone, to The SKIN Report. I am really excited about today’s episode. We have Dr. Rak on today. Dr. Rak is a lifestyle medicine physician in the San Francisco Bay Area, but of course, he also sees patients, virtually, in his practice. Today, we are going to talk about testosterone replacement in men and women, and some of the dangers of it, some of the benefit, and how you can safely go about deciding if it is something that is right for you, and so forth.

Dr. Rak Jotwani:
Ah, Simran, it’s such a pleasure to be here. Thank you for the time and inviting me. And yeah, it seems like many moons ago that we worked together and since that time, yeah, a lot of things have changed. I, myself, I guess you don’t realize, I actually didn’t finish my nephrology training. So, I got partway through the fellowship and I sort of realized that that wasn’t exactly what I wanted to do, but I didn’t know what I wanted to do. So, I went to go work as a hospitalist. For your listeners, that’s someone who takes care of patients who get hospitalized, generally a general internal medicine doctor. And I did that for 11 years and it was during that time that I sort of had this own reckoning, I would say, reckoning with my own health.

And I was taking care of people in the hospital. I was taking care of people who had heart attacks and strokes and complications of diabetes. I had pre-diabetes at that point as well. And so, it wasn’t easy, necessarily, but through some guidance and some, I say, synchronicity of the right people coming into my life, I made changes. One of those changes was adopting a whole food plant-based diet. And within really weeks to months of doing that, all those chronic conditions went away, and within a year I had lost 50 pounds. This was without even exercising. I hadn’t started exercising at that point.

And then I said, “Why aren’t we doing this for everyone? Why am I in the hospital and we’re waiting, almost, for people to come in with blockages in their heart or in their brain when we know this life-saving, I’d call it life-saving treatment, exists, where you change the food you eat and how you move your body and how you manage stress?” And in 2017, I got certified in lifestyle medicine. That’s through the American College of Lifestyle Medicine. That is really using lifestyle changes as a medicine to treat and reverse most of the chronic conditions. 80% of the chronic conditions we take care of are really driven by lifestyle factors.

So, I started my own virtual practice, and that is … You see the fist pump in the back, for anyone watching on video, that’s my logo, but it’s called Rak Your Life. And that’s what I do. I help people make lifestyle changes to take control of their health and reverse their disease and I say, live a life that is most fulfilling to your true potential.

Dr. Simran Sethi:
I’m so glad that as an internist, you took the time to go through the training that is focused on these, like you said, lifestyle changes that honestly, yes, you’re correct, most of our chronic conditions today are a result of lifestyle choices or frameworks. And many physicians, and actually, most physicians are not trained on lifestyle medicine during medical school or during medical residency.

And like you, I used to work in the hospital as well, as a hospitalist. And working in a hospital is basically there’s no preventative care. Right? It’s a reactive sort of care. And when you talk to your patients, you realize that even if they want to make big changes in their lifestyle to address chronic conditions, there isn’t a lot of guidance or the guidance is suboptimal. We live in a very capitalist society, and so, there are a lot of companies that are not physician directed, who say, “Oh wow, people with diabetes looking for weight reduction,” or so forth, “and let’s offer one solution, one blanket solution and see if we can market to them.” And that’s sad because the consumers don’t know that a lot of times.

So today, actually, our topic is another example of that. Testosterone replacement is something that is widely marketed mostly to men. And when you go and dig in, you’ll see that most of the places that offer testosterone replacement are not actually physician practices, or they are practices, but they’re owned and operated by some business entity and they have providers there who are not really trained to do testosterone replacement or hormone replacement properly. Partly because they don’t have the background of someone like an internal medicine doctor, to understand what are the consequences of incorrect or suboptimal treatment. So, let’s start with who is the ideal candidate for testosterone replacement?

Dr. Rak Jotwani:

Dr. Simran Sethi:
And then, who do you find tends to do it?

Dr. Rak Jotwani:
Testosterone, it’s a hormone, it’s an androgenic hormone that is produced. And some individuals have what we call hypogonadism, where they actually do produce less testosterone, and that’s diagnosed with a blood test. So, a doctor can check your total and free testosterone level, and if they confirm that you have low testosterone levels along with symptoms, so symptoms of low testosterone may be … And they’re kind of non-specific, but they’re fatigue, decreased libido, erectile dysfunction. That case, someone who’s truly hypogonad and has those symptoms, then testosterone replacement is indicated.

And then, there are some medical conditions like certain genetic disorders or pituitary gland disorders, men who have lost their testicles, for example, because of surgery. There are legitimate indications for using the drug. So, I don’t want to start this conversation by saying no one should be on testosterone replacement therapy, but I think what you’re getting at and what we’ll talk about is that there’s misuse, there’s overuse and there’s misuse. And why we’re seeing all these, like you said, these venture capital-backed virtual practices now, where they’re overtly marketing to men, “Come for a monthly membership. We’ll prescribe testosterone replacement therapy.” Or, they’re prescribing clomiphene or other medicines, basically to try and increase testosterone levels.

Dr. Simran Sethi:
Of course, the biggest marketing message here is that, “We’ll just give you a little bit of testosterone and that’s going to make your fatigue go. It’s going to make you grow bigger muscles or increase your metabolism and make you more focused.” There are also women who are marketed testosterone, not as much as men.
In your practice, have you seen patients who are not people with hypogonadism and people with actual low testosterone, who’ve perhaps in the past done these kind of therapies?

Dr. Rak Jotwani:
First, I would say this speaks to larger societal portrayal of what the ideal male aesthetic should be. And so, you see superhero movies and pretty much every Hollywood actor now is super jacked and has a big muscular frame. And so, that has become the ideal and the goal for so many men. They look at all these magazines. Now, of course, this is nothing new, for women, I think the problem is probably worse in terms of having these unrealistic expectations of what one should look like. But in men, there are increasingly then the use of hormones. And it’s not just testosterone. I mean, this also gets at anabolic steroids that many men are using. And it’s at this point, you can just go online and order it from … I don’t even know where it’s coming from, but there’s all these websites that are just selling these drugs.

There’s other drugs that aren’t even approved for human use, that people are buying. They’re sold under research chemicals. And because they have this androgenic effect, because there is this desire, there is this strong desire for men to look a certain way, have a certain aesthetic. So, I think that’s where this is coming from. Why are venture capital firms going into this? Because there’s a demand for it. Because they know they can make money. There are a lot of men who are seeking this type of therapy.

Now, you talk about steroids and somebody would say, “Oh, that’s illicit. I’m not going to do that. But if I go to a clinic and a doctor or a chiropractor or a physician’s assistant prescribes me testosterone replacement, then great, I’m doing something above the bar. I’m getting medical therapy.” Right? But there’s not a clear medical indication in many of these cases. They may have normal levels or even borderline levels. And we can talk about why male or men testosterone levels, in general, can be low and how to address that before you even think about putting someone on testosterone replacement therapy.

But there’s these soft indications. They’re putting them on therapy because … Sometimes it’s referred … And I don’t love the term because I practice lifestyle medicine, but it’s been referred to as lifestyle TRT or lifestyle testosterone replacement, because people are doing it, basically, to enhance their physical appearance and their performance. And it’s true, if I were to go on testosterone and continue to work out and eat the same way I’m eating right now, I’d put on more muscle and I would probably lose some fat because it’s an anabolic hormone, it has that effect in the body, but it’s not without risks. And we can talk about that as well.

Dr. Simran Sethi:
How does testosterone vary and why, with age, in men?

Dr. Rak Jotwani:
As you get older, definitely your testosterone levels will come down, and there’s all these other whole slew of lifestyle factors that lead to decreased testosterone. The biggest one, I would say, is probably the diet and extra adiposity. So, having extra body weight, particularly abdominal fat and visceral fat, will lead to reduction in production of testosterone.

So, generally speaking, in our country, in the Western world, as people get older, they tend to increase adiposity and body weight. So, it’s not just that people are getting older and they’re producing less testosterone, although that is part of it, but it’s also that these lifestyle factors then conglomerate and make the production even less. So, I think over time you’ll see men in their … Now it’s even younger, but really 30s, 40s, 50s, where they’re like, “My libido is not as good as it was. I’m losing muscle mass. I’m gaining fat.” And they think that, “Oh, it must be because I’m producing less testosterone.” Not the other way around, like, “My lifestyle factors are contributing to these things, and as a result, I’m producing less testosterone.”

Dr. Simran Sethi:
People who, again, as they’re aging, they want to increase their muscle mass, performance, and they start using testosterone or get testosterone replacement therapy. What are some of the side effects that they need to watch out for?

Dr. Rak Jotwani:
Short-term side effects, not so much. I mean, usually, testosterone is given as an injection, so people can have injection site reaction, or some people have an intolerance. I’ve seen people actually have allergic reaction. It may be something else in the vehicle or the medicines.

There are legitimate health risks of testosterone. So, this is why I say, unless somebody absolutely needs it, and when I say that, I mean, somebody who has indication like they’re hypogonad or they have decreased production, and they’ve failed lifestyle interventions. So, we can talk about that. There’s certain lifestyle interventions, basically like when you lose that adiposity, when you lose body fat and when you do start actually strength training regularly, testosterone levels will go up.

The long-term risks of testosterone replacement therapy, meaning, if you can avoid being on it, you should. You should want to avoid it. There are cardiovascular issues. So, we know it increases the viscosity of blood, meaning you’re more likely potentially to form clots and that increases your risk of vascular complications like heart attacks, strokes.

There can be prostate issues. So, the prostate enlarges in the presence of testosterone, so prostate hypertrophy where men have a harder time urinating. Prostate cancer is the most common cause of cancer in men. Many men are undiagnosed. For many men it doesn’t cause problems, but testosterone is actually a stimulator of undiagnosed prostate cancer. So, it can actually exacerbate underlying prostate cancer.

There’s just psychological effects. Like you go on a hormone therapy and it can increase aggression, it can cause mood swings, it can worsen underlying mental health issues. So, I’ve seen people go on therapy and their underlying anxiety or their underlying depression gets worse.

And then, ultimately, you’re also suppressing natural testosterone production. I don’t think people realize when they’re going on therapy that this can actually have long-term consequences. It can lead to testicular atrophy. It does, over time, and then infertility. And so, young men going on testosterone may not be adequately counseled or they may be signing something … I think the big problem with a lot of these clinics is, and you mentioned it, is that there’s easier access, but there’s often less or minimal medical oversight. And these are not benign therapies.

Dr. Simran Sethi:
The one thing that people don’t understand about a lot of hormones in the body is that they have a negative feedback loop. Meaning, that if you exogenously are supplementing, you’re actually then driving down your own natural production of that same hormone. And if you do this for a long enough time, you’re going to suppress it to a point where you almost can rehabilitate that production in the future. And yes, that is something that, I think, really most people are not counseled about.

And would you say that there is a period of time that you can say, “Okay. If you’ve used testosterone replacement for this period of time, the chances are that you are still going to be okay when you get off of it”?

Dr. Rak Jotwani:
I don’t know the answer to that, to be honest. I think, obviously, the shorter the time someone’s on therapy … But this gets back to why are you going on therapy? So, if you’re going on it for a quick fix and you’re like, “Oh, let me just minimize…” I mean, a lot of men, a lot of bodybuilders, for example, they will use testosterone after or during when they’re using anabolic steroid, because the steroids themselves suppress natural testosterone production. And so, then suddenly they don’t have any testosterone. They have this very anabolic hormone that doesn’t have all the functions of testosterone, so they have to take testosterone on top of it. And then, they will try to mitigate that afterwards. They’ll take other medicines to try and increase natural testosterone.

All of this is not how we were designed to function, right? We’re sort of messing up with this beautiful machine that we are. And so, playing with one thing inevitably leads to all these downstream consequences.

Dr. Simran Sethi:
If somebody did want to go … If they’re on testosterone replacement and they’re like, “You know what? I do want to get off of this.” What should they be doing?

Dr. Rak Jotwani:
Yeah. First, I would meet with a doctor, your primary care doctor, and maybe in that case, maybe even get referral to a hormone specialist we call an endocrinologist. There are some therapies that can sometimes help boost natural testosterone therapy, but that’s probably best directed by either internist or an endocrinologist. And there’s a question mark then. When they come off of it they’ll say, “Okay, well, we’ll have to see what happens.” It’s not inevitable that somebody won’t be able to come off therapy. Again, it’s the degree to which … How much time have they been on it and how big of a dose were they on, that will speak to how much suppression they have, and really, did they have true long-term testicular atrophy?

That’s really a question mark when somebody comes off, but it is possible. It is possible. And some people, it can take quite a bit of time. It can take a year or two years to get back to normal functioning, but I’ve seen that as well, but that is definitely possible. So, if someone listening is like, “Oh, I’m on therapy.” Or, “I’ve maybe used some of these compounds and now I don’t want to be increased risk of getting a heart attack or a stroke.” That’s the step is go talk to your doctor, potentially see an endocrinologist and then come off. And that coming off period isn’t necessarily the most pleasant either, because then you go through a lot of those symptoms of lower testosterone before your natural production kicks in.

Dr. Simran Sethi:
It’s addressing, why are you even considering it or why are you even on testosterone? What could you do alternatively, that is going to naturally increase your testosterone production, like diet and exercise? And I know diet and exercise, easier said than done, and extremely broad too. Some people call exercise weightlifting. Some people call it running. Some people call it just walking.

Dr. Rak Jotwani:
We live in a society now where I think everyone is looking for a magic pill or an injection or something that will get us the results, but not necessarily require the effort and the work that is required. Can you get a super muscular physique? I mean, there are natural bodybuilders. There are athletes who are tested regularly. They don’t take these substances, but they put in a lot of time and effort, right? And their diet is very regimen.

And I’m not even suggesting most people need to do that for good health. I think that speaks to the kind of perverse body dysmorphia and expectations that people have in our society of what we should look like. But if that is your goal and you want to do it in a natural way, that requires a lot of work, it requires a lot of effort.

The other part of your question is, what are the specific things? Because you’re right, when you say exercise, does walking … I would say, any amount of exercise that is going to improve your metabolic health probably will improve overall testosterone production, but specifically, and I mentioned it before, but strength training, lifting weights, and then gradually increasing the weight and the intensity or what we call progressive overload. That has been shown to significantly boost testosterone levels. And also, high intensity training or high intensity interval training, where you do short bursts of more intense exercise with rest periods actually can increase testosterone. As opposed to steady state cardio, which probably doesn’t have as much of an impact on testosterone.

And then, diet. Really making sure you eat a variety of whole foods, whole plants in particular, and then healthy fats which support … And I say, get it from whole foods like avocados and nuts and seeds and things like that. Those are really important for hormone synthesis because the backbone of testosterone is actually cholesterol, and people think, “Oh, then I have to get cholesterol in my diet.” You don’t have to get cholesterol in your diet. We synthesize cholesterol, but we synthesize it from healthy fats.

Dr. Simran Sethi:
In our society, yes, there’s this desire to get something quickly, and of course, everyone wants things easier, but also there’s a lot of information exchange, a lot of platforms for information exchange. Social media, Instagram, YouTube, TikTok, and of course, podcasts. And a lot of people who don’t come from, let’s say, a medical background for something like testosterone replacement. There are a lot of people who’ve had experience with it, patients or bodybuilders, and so forth, who’ve used it, that sometimes guide that journey. Which, you’re right, there are a lot of risks to it, and a lot of people are not aware of those.

But with that same theme, I would love to have you on another episode where I’d like to discuss weight loss with drugs like Ozempic, semaglutide, and how it affects men, actually, and what are alternative ways to achieve weight loss. And because I think that men and women have different bodies and they also sometimes have different goals. So, I would love to have you back. And in your lifestyle medicine practice, I’m sure this is a big part.

Dr. Rak Jotwani:
Oh yeah, this comes up a lot. Yeah. Yeah. Yeah. Yeah. Oh, I’d love to come back and talk about that. I’m fascinated with these drugs, and I do think they have a place, and I do think they’re also a pharmaceutical response to our food environment. But yeah, I would love to delve into that more with you.

Dr. Simran Sethi:
Yeah. Exactly. Because I think that, like you said, they can be beneficial, but it is, how can you derive the benefit with the ability to then stop being dependent on that? If any of the listeners want to find you, because you also have a podcast, and can you tell us a little bit of how they could do that?

Dr. Rak Jotwani:
Sure. Yeah. So, you can go to my website, which is Rak Your Life, R-A-K-Y-O-U-R-L-I-F-E.com. And there, you can out how to work with me. I’m licensed in actually 10 states, so including California, New York, Florida, Texas. And I also run health education groups. Those are called tribes. You can be anywhere for those. And so, you can find information on that.

We have memberships, and I do monthly cook-alongs, and I do webinars on breath work. And I do have a podcast. I co-host it with a good friend of mine. His name is Po. And he is on his own health journey, and we like to say he’s the hero and I’m the guide. And it’s called The Health Feast, because I think so many times, health gets portrayed and people look at good health as a chore or a punishment, and really, it’s an opportunity to feel good and to live a fulfilling life. And the way to do that is to make it into a feast, to indulge on it, to have it be a joyous and abundant experience. So, we have guests on and delve into how to make good health a feast in your life.

Dr. Simran Sethi:
Thank you for being with us today, Dr. Rak. And I am really looking forward to our next episode together.

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