Harder Erections! Viagra & Cialis work but hear tips on how to take them from these doctors!

Hello everyone and welcome to Revmd sex spikes  podcast with me your host Dr Debra Durst and my co-host Farideh. Hey guys Farideh Golembiewski nurse practitioner here at RevitalyzeMD and today we have a special guest with us and I'll let him  introduce himself hello there I'm George Ibrahim at Biltmore Restorative of medicine in Asheville  North Carolina DrIbrahim is with Asheville restorative right so that you know and again  we've been friends for a long time now and he does a very similar business and we both do sexual  Wellness so that's what we're going to talk about today we have a great podcast but I want to again  kind of prompt you to like And subscribe early if you like content that's going to improve your  sex life then you will get alerts as to other podcasts today I think the first thing we'll talk  about then is maybe the Cialis Viagra the little blue pill what do you think George one of the  first things I always tell guys is when we were in our 20s yeah I'm old but when we are twins  and we could you know perform pretty regularly whenever we wanted to backer hadn't been invented  yet we had the foundation it was testosterone so you know the vast majority of guys who come in and  that's what they're looking for Cialis or Viagra I go well your deficiencies probably by Viagra or  Cialis it's more than likely testosterone but then once a guy's been optimized from a testosterone  level they're going to be some men that are going to need some extra help and I think that's when  Cialis and bagger come into play but only after they've optimized their testosterone levels  yeah so hormones first hormones yeah absolutely and just to give you a little background too  DrAbraham is like a um urologist by trade Duke trained and so his background in this  is extensive so and he's been doing hormone replacement for a long time so an expert in the  field so when we're talking about them coming in and they're you know 30s 40s 50s and Beyond HRT or  hormone replacement and optimal optimization first absolutely yeah and then once that's optimized  they still need a little bit more then going to the Cialis or Viagra I think is a very safe and  reliable option for some men you know there's a trade-off I do believe Viagra is a Little Bit  Stronger but then it does have bigger side effects um Cialis not as many side effects but I don't  think it has as big of a umph or an effect I tell guys you know I look at it as Coke and Pepsi when  let's pick the one that doesn't prefer I don't think one's any better than the other it's just  you know it's up to the guy I think the biggest issue is when primary care has just written  them a prescription and didn't bother educating the patient on how to take it properly that the  biggest you find those as the biggest problems with patients doing it right they do it wrong  you know most guys that can go out let's just say date night they come home they've eaten this big  old steak baked potato dessert belly's full you know she might be in the back room changing into  something sexy he then goes in the bathroom pops a little blue pill they hop into the bed it's not  going to work you cannot take it on a full stomach Cialis is not as bad but Viagra and a full  stomach it's it's not going to be absorbed for four to five hours and and that's the big  you know that's where these guys get destroyed on it I tell my guys take it before you go out to  eat it's gonna be around in three or four hours and when you come home and you take it on a full  stomach forget about it ready the next morning but you're not going to have anything in your body  that's going to be working that evening empty stomach empty stomach empty stomach is really the  only way to take either of these two medications what's your opinion on daily Cialis what about  this first of all it takes an entire month to work up to the therapeutic effect of 120  milligrams Cialis so the guys that are doing the daily five milligrams you just tell them don't  even think that this is going to do anything for you for at least a month so that's huge because  you know there are guys that will do the daily and by daily they mean two or three times a week  you can't do that you've got to take the daily every single day and it takes a month before it  starts to work so I don't think that's a problem you know my bias is the older guys pretty much  have an idea of when they're going to be active so why bother with taking something every day  when you know that it might be your certain days of the week that you're going to be active the  younger guys where there's more spontaneity uh more surprises I like to say I I think they're  better off doing the the daily because you know they're they're less yeah and then you don't  think that Cialis has as much a problem but it still has to be on an empty stomach yeah but  not as big an issue exactly but at the end of the day you're going to confuse patients I just  don't just do it on an empty stomach yeah and then the other biggie that we you know have a  little ditty in the office that we tell guys faces red time for bed until they have that facial  flush took a little something that's a good saying I like that George face is red time for bed if  it's not if if you don't see it in your face it's not working down there and then you got the guys  that know they're going to get nasal congestion I I mean I've seen this happen more  often than you can shake a stick at you got to tell them look you don't take Sudafed  guys I know you're going to get a little you know sinus runniness you know your nose is going to  run you might get congested but Sudafed destroys erections yep counterproductive yeah you know  I've I've had guys come in they tell me I'll religiously take my Sudafed every time I take my  bagger because I don't want to get that stuffy nose I go well guess what else you're not going to  get an erection either that's a guarantee it's not gonna happen so the um again I've heard it so many  times and I'm sure you have to where they're going out to dinner and they're afraid that they're  going to get an erection you know if they take it too early and you hear that over and over again  so I think they're just not being instructed well um but the by the docs that are actually writing  the prescriptions most of the time yeah and you know Viagra and Cialis don't cause erections  they help sustain and promote an erection that has to be caused by something else you can take  as much Viagra as you want to you're not going to spontaneously become a wrecked something has  to happen to get it to the start flowing starting point yeah but it's just you're not just going  to pop an erection sitting at the table unless something's you know arousing you what's your  opinion on nitric oxide as a supplement to help increase blood flow I I think that I think it's  fantastic I mean that's you know where Viagra is getting basically it's starting to work and having  more nitric oxide on board is a great thing to do with the Viagra in the Cialis or do you ever have  patients who recommend doing it as an independent supplement if they can get away with it as  an independent supper that's one less thing oh guys I think they can get away with it that's  it they all think that nail originally early on anyhow early yeah I definitely think it helps  diagrams us work I you know they're not really that bad off at all if that's all they need is a  little bit of nitric oxide you know correct well and so we ended up recently looking and I don't  know if you and I spoke since at like um Berkeley life it's a nitric oxide supplement and where it  has all the nitrates necessary for the conversion and the enzyme to work which was great too and  they have little strips so I don't know if we'd ever the little strips you can test to see where  your nitrate level is and then you actually take a couple of the capsules and you can retest and  it's like having beets and spinach and all that in like a little capsule form way more effective  than L-Arginine which has to convert yeah correct yeah so when they take I'm sorry what is it those  those tabs are effective yeah well and we recently did have a compounding pharmacist and I don't know  again if we spoke about the combination but Tim was the one that brought us the Berkeley life  product just saying again he sees a lot more of the pd5 Inhibitors Cialis Swagger work with it  and but he does a combination troki I know you use the same compounding pharmacy we do but yeah  um I've used them okay I mean what you're doing is you're trading down a little of the um dosage  on the Viagra your supplemented with someone the Cialis do you have to um I mean could you get  just as a bit of a result using one versus the other probably where I'm seeing it beneficial  is my guys that have side effects on high dose Viagra they seem to do a little bit better being  able to have a little bit of a lower dose still getting that Cialis that different pathway and  they're able to manage and get erections and keep them so that's where I've seen it most effective  please one of the reasons why the lozenges work um really well is the whole idea you're trying  to get as much buccal or absorption through the mouth rather than through the stomach because once  again the guy's going to have eaten a big dinner have to time and doing a trophy or Eliza they  absorb it through their mouth then they bypass that full stomach and so I prefer lozenges over  the tablets only because I don't care how often you tell these guys until they find you off it  makes a difference they really don't realize that the full stomach makes a difference I just  think they don't hear you that's all like you know there's some selectivity what is that think about  10 of what we say to them in the office exactly they may hear more from you but yeah sometimes  there's the selectivity with an XY occasionally so maybe that's it but but I think the big thing  is like is urologists are really if anything going more towards the pill in the little blue pill or  via grocialis as a treatment for what they need instead of more comprehensively doing it looking  at the hormones and everything hormones and everything else so if we wanted to talk a little  bit about you know what other things they can do because they're coming to us because they're not  getting a response to or they're getting side effects with and so how we address it otherwise  to at least touch on the pill worked and now it doesn't can we hear that often the biggest thing  you know you're doing hormones I'm doing hormones I'm a urologist the number of times though that I  write for Viagra and see Alice in the given month is so few yeah because you know testosterone  is doing such a big job I mean testosterone is a basodilator it helps with libido biography  house don't do any of that um yeah then we have the other new peptides pt-141 I think is going to  be a Blockbuster in the future uh and you know I think it's going to take the place of Viagra um  down the road I mean you know it's got a little bit different side effects that we have to teach  patients about but I think pt141 is a quiet roster and pt-141 being a different pathway too so not  even needing a stateless like like you do with the um with Cialis and Viagra the pd5 Inhibitors  you don't need a stimulus that can be spontaneous yeah oh yeah yeah so timing timing is vague with  that one key huh figure out the timing but you found that a lot of patients love pt141 they do I  mean you know we have a pretty nice protocol that Maps out how to begin adjusting the dose and  monitoring the time to effect because it is so variable and the podcast is not the place to get  into it but oh yeah yeah the thing about pt141 is that is not take two and call me in the morning  everybody yeah no correct and it's different for them both side effect profile and timing so yeah  that's huge but once they figure it out you know it's pretty real um unrepeatable but they got to  figure out what their time frame is going to be and what dose is going to be correct and those are  again you know adjuncts to really kind of our core treatments for you know sexual sexual Wellness  Sexual Health in men because really when we're talking about performance number one as they age  its hormone declines so hormones first and men are easier than women with that as you well know yes  so it's one hormone versus managing a second yeah yeah well and I don't mean to interrupt you um  while men are easier men are more stubborn women go through menopause and it hits them like a ton  of bricks but men lose testosterone Every Man's losing it beginning around the age of 25 at about  rate of two to four percent they're losing it little by little so that by the time a man is 50  100 of men have lost 50 percent of what their Peak levels were I'm sorry you can drive a Maserati  with the tires halfway inflated it's not going to perform though no guy in the world would think  that a Maserati is going to perform the tires have inflated but then here he is thinking he doesn't  need help or need more testosterone with his testosterone levels are happening yeah yeah yeah  yeah you know and then by the time they're 60 it's down to a third and you know if you can get these  guys realize I don't care how veril they think they are they're still a third of what they were  when they were in their 20s if they're 60 years old period every man you're right very stubborn  because we have guys in front of us coming in for evaluation and they're like well I don't have  a problem I don't really know why I'm here it's like all right the wife the wife or partner brings  them in and they're sitting in front of us with like all the the good marks yeah all of them and  they're like I'm totally fine I'm like all right we'll just get blood we'll go from there you go  through the symptoms of andropause and you know the number one thing I always have on the slide  is fall asleep after dinner and that woman you know points to the slide you know like yeah yeah  yeah tired all the time every single one of those are you yeah well and then again like when they  and they'll go through like two or three people by the time they get to fair day all right in the  back and everything's perfect and they come back and they're like they don't have anything wrong  and there's nothing wrong with them I'm like well they're here there's something wrong yeah yeah and  it's so they I agree with you like again they're more denial you know than um than a woman is  for sure I mean think women can be there too but they're not in front of us when they're denying  they're in front of us because they want help and and men are still somewhat denying you got to kind  of slowly open that conversation a little more um with them they're not always willing  to even when the partner brings them in but so the hormone is one of them and I  love that you know again it's and I love when they ask us also you know if everything  you know if this will fix everything whether it's for Mormons or they gains wave  and P shot which we'll just touch on um you know I'm like the only guarantee is really  that everything's going to get worse with time if not addressed right absolutely exactly yeah you  know how this plays out in the end if they let it go and it's harder to treat the 60 year old house  with no maintenance over 60 years right yeah and they didn't know we could do it before but again  so the urologists and traditional doctors are only offering them prescription Cialis Viagra right  really not offering anything else no we hear so often well my doc said my testosterone levels are  normal well that scale is 264 to 916 if you look at LabCorp I mean it doesn't fit in that just  about every man what is your response to that usually George Well my response first of all I go  where does it say normal on this Library it says reference interval yeah and like you said 216 is  that 2. 5 percentile and 924 or whatever the high number is is at 97.

5 percentile exactly this is  taken from an average of men who are aged 19 to 39 I'm sorry but most of our men are a little  bit older than that yeah which has nothing to do with it you know and I just tell them I don't  care what that number says if you're 60 years old it's a third of what it was when you were 25. just  because it falls between two and a half percent what man would drive his car with 2. 5 percent  of the oil in the crankcase no nothing because it's gone blue yeah but they think that yeah it's  normal now it doesn't say normal it just doesn't say l or low which happens below 2.

5 percentile  so you know I hate that reference range up there because two minutes I just mark it out yeah yes  ignore that yeah yeah ignore it but again that's like the most common thing like I'm tested and oh  everything's normal they're 70.