How To Treat Erectile Dysfunction Without The Little Blue Pill | George Papanicolaou & Mark Hyman

see all that blue pill does is fix that end problem right it fixes that let's just make sure we get the erection and we maintain it but there's reasons why we get there hi everyone just wanted to let you know that this episode contains some colorful language so if you're listening with kids you might want to save this episode for later [Music] welcome to the doctor's pharmacy i'm dr mark hyman and that's pharmacy with nf far macy a place for conversations that matter and if you're a guy listening to this or you're a woman who has a guy you better listen up because this is about a very common problem it's known as ed otherwise known as erectile dysfunction which is a very very common problem we're going to get into that and today our guest is none other than dr george papanicola who's one of our key physicians here at the ultra wellness center who is an extraordinary physician is doing great work here and we are just so excited to talk about this topic aren't we george thrilled absolutely it's a little uncomfortable but i guess we're gonna have to get into it because we're doctors and we're professionals so we can really we can really talk about it so george this is a big problem uh guys are having trouble women also have a lot of sexual dysfunction uh we're going to maybe cover that on another podcast today i want to talk about male erectile dysfunction with you because it's it's it's such a big issue the the lucky accident of a failed drug experiment for a blood pressure drug led to the development of viagra which i talked about on a podcast with dr louis ignarro who is the discoverer of nitric oxide which is a little molecule that causes your blood vessels to dilate and that's how viagra works it was meant to be a blood pressure pill but it didn't work so good but it worked better for the side effects that the guys got and and all of a sudden it was a blockbuster pill like blockbuster which means that people needed it so so tell us about the history of of um of this whole story and the prevalence how common it is and and what what is going on why are we seeing such an epidemic of this well see one of the key things was in 1998 when viagra hit the scene it really opened the door for men to have an opportunity to talk about what had been going on for centuries and that was erectile dysfunction so great viagra was awesome not only did it work but it opened the door for that conversation because 10 of men under the age of 40 have erectile dysfunction and by the time you're 70 you have a 60 chance of having a rectangle 70 or 60. no 60 percent chance by the time you're 70. by the time you're 70 of having erectile dysfunction so that's a lot of people having erectile dysfunction and people's sex lives are not over at age you know 50 60 or 70 there are men that come to me wanting to have prescriptions for viagra at age 70.

and i always tell them i'm not giving it to you unless they get a pers i get a written note from your wife that's not going to go well actually yesterday i was doing a console with a patient who was 87 years old yeah who's still having sex with his wife i don't plan on it yeah i'm going at least to 100. i don't know getting better as time goes on so why stop that's exactly right so this is a very common problem from a traditional medicine point of view there really wasn't much of an approach to this beforehand we had some really coarse and crude treatments talk about what the traditional approach to erectile dysfunction has been other than the viagra silas and levitra category of drugs which now are pretty widely prescribed and do work and help people yeah so you know prior to viagra there were some fairly primitive approaches to it like vacuum pumps and revascularization because vascular you know vascular issues endothelial dysfunction uh is is a key part of what causes erectile dysfunction so in english you're basically saying that you get hardening of the arteries in your penis which makes it not so hard right so but that hardening of the arteries not only reduces blood flow but there's this endothelial dysfunction and it's in the endothelial cells that nitrous oxide has its effect so what are what are endothelial cells endothelial cells are the cells that are are lining the blood vessels of the that that are inside the penis so throughout your entire body you've got these lining of all your blood vessels and it's it's a very active lining it does all kinds of things including regulate the dilation and the blood flow and lots of other things inflammation and nitric oxide is a key regulator of that very key and that's and that's what goes wrong and and what are the reasons why that men tend to get this decreased blood flow in the penis that leads to these erectile dysfunction there's there's multiple reasons but before we go on to that i think probably is a good idea just let me just review quickly because we're going to talk about nitrous oxide we're going to talk about why viagra works and other drugs like it essentially what happens is that you have the release of nitrous oxide nitric oxide nitrous nitrous oxide disease laughing gas i'm just going to call it n-o okay n-o so you release the n-o and then n-o has ac it's action on the endothelial cells inside the blood vessels of the penis it also acts on the corpus cavernosa muscles and so you get the simultaneous relaxation of those muscles so blood can flow in those are the big muscles of the penis so that when they're full of blood they actually start the erection and maintain the erection and then you have the small blood vessels nitrous oxide acts on those at the same time and causes those to constrict so the blood that flows into the cavernous muscles then stays there as these small veins constrict and that basically starts the erection and maintains the erection and what happens is you have and that's called tumin essence then you have detuminescence when the the after the ejaculation the penis relaxes and that's when five phosphodiesterase breaks down the compound that was responsible for causing that relaxation and constriction and when that compound breaks down those small blood vessels relax and the penis relaxes and becomes flaccid it's five fuc it's the five fostered diastrates that gets inhibited by viagra yes right so this is just a little less than everybody listening that's how it works viagra blocks the five um five phosphodiesterase allows this basically it increases blood flow and makes the erection stay longer because you don't get the breakdown of this thing called cyclic gmp so that doesn't break down that maintains the the constriction of those small blood vessels you can maintain actually obtain an erection and sustain an erection for a longer period it's a good thing you have to remember all those chemical names when you're having sex because that would not go very far no so but that's what's going on and so so then what can affect what are the things that affect that so metabolic syndrome so when you're when you're thinking about people with um ed see all that blue pill does is fix that end problem right it fixes that let's just make sure we get the erection and we maintain it but there's reasons why we get there we get there because of stress and its impact on that nora that very very sensitive neurovascular problem that neurovascular is not a problem that neurovascular symphony has to occur for you to have you know your erection and ejaculation so metabolic syndrome that's pre-diabetes which is pre-body pre-diabetes which includes you know to make that diagnosis you have to have obesity dyslipidemia which is just abnormal cholesterol triglycerides hdls uh you have to have hypertension and one of the things is insulin resistance and so insulin resistance is connected to endothelial dysfunction when those endothelial cells aren't working then the the no the nitrous oxide is not going to have an impact and you're not going to be able to start that erection so would you treat you can give the person viagra but since metabolic syndrome has so many other impacts on their overall health and their their health span and lifespan it'd be better to fix that right okay so let me let me translate that because that was that was really good i think i think here's what's going on basically people are eating lots of sugar and starch and crap in their diet get pre-diabetes which goes along with you know high triglycerides low hdl high blood pressure belly fat the whole the whole thing exactly and when you have this problem which by the way affects every other american and if you take out the kids it's probably more than half the adults right so we've got 75 percent overweight 88 metabolically and healthy in this country most of those people have some degree of insulin resistance and what you're saying is when you have this phenomena going on in your body it damages the ability of the lining of your arteries to function properly so you can't get blood flow in your organs not just in your penis but in your heart and in your brain which is why insulin resistance causes heart attacks and strokes and also dementia so this is all connected and in fact the first sign of heart disease is probably having trouble getting an erection you're worried about your erection but you know what you better be worried about your heart and your brain because they're the ones that are really the target of what's going on absolutely and i think people don't realize that it's not just a local problem it's just a systemic problem and so that's one of the points i really hoped would make today because you know as important as erections are it's getting those root causes that impact your overall health and then the cherry on top of the pie is greater actions yeah and i think i think most people don't realize that that you know our our whole system is connected and that's what's so different about functional medicine is that it's looking at the whole system so you know most people don't think of your diet when you think about having sexual dysfunction but that's the first thing we think about right right we do think about stress for sure that plays a role but there's alcohol there's alcohol you know and one of the roles that alcohol plays is that when you're when you're drinking alcohol that itself is going to impact that endothelial this function during the time of your use and you're going to maybe that night not have an erection here's here's what happens you can stop drinking and say okay that will fix it but there's something that happened you had this you have you can have a psychogenic response it's called performance anxiety and once you once for some men once they have a failure it multiplies itself they get performance anxiety and it becomes a psychogenic problem and there's a vast majority of men who have erectile dysfunction actually have a performance anxiety or psychogenic cause so basically just if it doesn't work once you're going to be afraid it doesn't work every time and that's going to make the whole thing worse yeah yeah so that's that's a hard mental thing to fix but the um the fascinating thing to me is that the the phenomena around seeing this as a systemic metabolic vascular issue is so is so important and there's a lot of ways to address it that you know we're going to get into um and of course there's a lot of ways to also address erectile dysfunction that are up and coming that are quite new just far beyond viagra which we're going to talk about i'm excited to talk about those things but but even in traditional medicine you've got the vacuum pump which is pre-viagra where you put a little ring around the base your penis and you basically put a tube around your penis and you basically vacuum it all the blood in there which just doesn't sound like fun to me and there's penile implants which can work uh there's there's alprostadil which is uh an injection or something that goes inside inside the urethra and the penis that can help that's a prostaglandin and there's revascularization which is a something i would love you to talk a little bit about so revascularization is essentially you're having as we talked about hardening of the arteries and it's there's two ways that can be done just like you have angioplasty your stents placed in the heart the same thing can be done for the penis and that's that's one possibility it's uh so it's basically angioplasty for your penis yeah wow that's incredible uh and and um i know yeah again these are these are very interesting very interesting responses to the problem but i would yeah and we're going to go through other possibilities as you said we're going to talk about stem cells and platelet-rich plasma um i always like to go back to the idea that yeah you can be revascularized by why get there in the first place exactly right you know it's like you get a stent but you got a fixture all of these things actually work i mean i i've had patients of mine use the vacuum pump i don't know how they do it it works doc i love it i've had people get penile implants it works doc i love it and they're pressing their testicle and they're getting their erection and you know that's how that's how the pump works you know they have the pump is inside one one testicle and you start pressing on it and it gives you your erection and it works i've had men use the injections they feel like 18 years old again but they all have diabetes hypertension metabolic syndrome and i can't get them to get to that underlying cause so almost sometimes when i not let them get their erections right well let's talk about let's talk about testosterone because there's this whole conversation up out there about male menopause or andropause and this whole syndrome of low t or low testosterone and i think part of it's gone to the extreme and there's a lot of bodybuilders use testosterone and i think it can be used inappropriately but but what i want you to talk about is why do we see the drop in testosterone as men age because i think this is really important there are natural ways to raise testosterone there are ways that we are living that lower testosterone so let's get into talking about that because if you fix testosterone a lot of things get better a lot of things do get better erections may or may not get better testosterone can definitely have an impact on erectile dysfunction it impacts the five phosphodiesterase we talked about earlier and it also can have an impact on nitric oxide and that can result in improved erections now you asked me why do we see this drop off in testosterone well there's this natural drop off of testosterone as men age so after the age of 30 you're losing about one percent per year and over time that's going to drop you pretty low but that's not going to do it all by itself now i've seen many older guys with raging high testosterone levels here's the older guys that don't have raging testosterones those are the guys that have sleep apnea alcohol over they drink too much alcohol they have diabetes they haven't learned how to manage their stress uh did i mention sleep apnea you did yeah i did but that's a very important one and so those are things that as you age begin to impact your body's ability to make testosterone yeah so i just want to emphasize something you said there it's so important you said diabetes but this whole pre-diabetes insulin resistance thing is the biggest reason so here's the deal the bigger your belly the lower your testosterone and the smaller [Laughter] the the more belly fat you have the lower your testosterone and and people don't understand that and then you mentioned alcohol and the reason alcohol is such a problem is that it increases a hormone a hormone converter called aromatase which is an enzyme that converts testosterone into estrogen which is why you see guys who are drinking lots of beer and alcohol have man boobs and have big bellies and lose the hair on their chest and lose their hair on their legs so they become more like women and they have very high estrogen levels so you people are shocked to find that out so you basically become like a woman the more alcohol you drink absolutely and i think those two things are really important for guys to understand because if you are struggling with erectile dysfunction it's a big deal for people and they don't understand that it's directly related to what they're eating now in addition to the fact that eating starch and sugar will lower your testosterone what are the things that actually might increase it from a dietary point of view mark it goes back to one of the books you read you wrote well eat fat get thin so now i'm going to tell you this the name of the book can now be the one that i'll write will be eat fat get hard oh gosh this is getting to be a racy podcast we've got to put explicit warnings on this one now yeah they shouldn't get us together this is gonna happen so yes fat because fat actually you know we've talked about this before has cholesterol on it cholesterol is not a bad guy cholesterol is really important foundational molecule for building hormones and one of them is testosterone that's right so eating good healthy fat is going to allow you to have that precursor molecule to maintain high levels of testosterone as long as you're doing everything else right sleeping well managing stress and limiting your alcohol use hey everybody it's dr hyman thanks for tuning into the doctor's pharmacy i hope you're loving this podcast it's one of my favorite things to do and introducing all the experts that i know and i love and that i've learned so much from and i want to tell you about something else i'm doing which is called mark's picks it's my weekly newsletter and in it i share my favorite stuff from 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com forward slash pics p-i-c-k-s and sign up for the newsletter and i'll share with you my favorite stuff that i use to enhance my health and get healthier and better and live younger longer now back to this week's episode so so let's talk about sort of a functional medicine approach to to addressing this because at a high level and then we want to get into some cases because from a functional medicine perspective we look at a lot of different things to try to identify why this person is having erectile dysfunction and or low testosterone which often go together so when someone comes in complaining of us what are the kinds of things you think about and what are the testing uh things that you look at so you know first off you know i want to make sure that i make the right diagnosis so you i always like to emphasize the fact that when people come to my office i'm going to get a timeline of events so i'm going to want to know everything that's happened and pretty much throughout their lifetime how they were born early eating habits early traumas and stressors in their lives disease patterns antibiotic use medication use trauma all of those things create a timeline and once you have that timeline you can then begin to piece together a narrative that leads you to the root cause or causes of their disease so it can be easy for a person to come in and tell me i have erectile dysfunction it started like three months ago when i tried to have an erection and i didn't have when i was with my girlfriend and ever since then i've been have been having a problem well oftentimes it's not as clear as the patient thinks it is and by asking them a long history i start to find out that maybe that wasn't the key turning point that he was slowly building up because of other issues maybe because of alcohol use maybe because of a family history of you know dyslipidemia and he has really high cholesterols and triglycerides and maybe early vascular disease it's really important to make sure we get to all those yeah and and not be biased by a patient opinion or what to identify so i really like to emphasize when we're talking about functional medicine we're talking about a detailed timeline and then we're talking about using the matrix and that matrix is it's just basically a paradigm we use that looks at systems and not symptoms it takes your conditions and it attaches them to your various systems so your cardiovascular system or your immune system or your gi system where we we break foods down we assimilate and we absorb we want to know how all those stories you're telling me how all the symptoms you've had how all of the the lifestyles you have are impacting those systems because they all work together that's right to get your body to work the way it's supposed to you have to deal with all those things inflammation like you mentioned that can affect endothelial function right you know toxins mercury lead talk about impacting endothelial mitochondrial function i mean those are major things and it's and just as a quick aside it's not a matter of whether you have heavy metals it's a matter of how much you have and how well you're how good you are detoxing so i also want to know about your your exposure to toxins so you that's how i start so so when i when someone comes in to see me i also think very similar to you and i go through the matrix but things i'm really focusing in on i'm looking at you know what is their diet are they eating an inflammatory diet because anything that causes inflammation will damage the blood vessel lyings and can affect blood flow uh which is processed food fried foods you know lack of protective foods that are anti-inflammatory those are really really important and that'll really dig into about looking at insulin resistance does this person have pre-diabetes we look at insulin levels we look at things that nobody really looks at traditionally i think the insulin resistance thing i i almost i would say 8 out of 10 of my patients that come here to the ultra wellness center don't just get a blood sugar or hemoglobin a1c they primarily are going to get a fasting glucose tolerance test that's the most sensitive way to uncover insulin resistance because insulin resistance can be hidden you know you know right you know if we use the current standards that we have of a fasting blood sugar of 100 you know that's not low enough you know it needs to be lower you know and so when you do a fasting insulin resistance test basically a person fasts and after that fast you give them 75 grams of sugar and then you see how their body responds how they how they produce insulin in response to that bolus of sugar and if they're able to keep that blood sugar at a normal range at lower levels of insulin we know that they have a very good carbohydrate metabolic glucose you know an efficient way of managing glucose but you're right but if if you see someone who's able to manage your sugar and insulin that's the key but i've seen patients who for example have normal sugars but their insulin insulin are high and here's here's the take-home point when you go to your doctor if you ask for a glucose tolerance test good luck if you're going to get it but if you get it they have to measure insulin and insulin is something that most doctors don't measure and you can measure fasting insulin right because most doctors don't even measure that if your insulin is over five you probably have an issue and if your triglycerides are higher hdl is low so i'm looking at all that i'm also thinking about you know what's going on with their testosterone levels so i'll look at total free testosterone i'll look at other markers so we get a really sense of what's their adrenal stress like do they have adrenal dysfunction are they chronically stressed we can look at things like dhea or we can look at other other other saliva cortisol and all the things you're mentioning are not things that you will get through your your primary care physician you know at harvard vanguard you know it's just not going to happen well you have to pick on harvard pretty much any anybody anybody got friends at heart all right but i do i do think you're right i think we're looking we're looking under the hood yeah we look under the hood and we have very specific tests that do that right you know we do someone someone said a functional regular medicine is like trying to diagnose what's wrong with your car by listening to the noises it makes functional medicine is basically looking at under the hood we look under the hood you know and it's and we don't guess we test and we happen to have really good tests at the ready and so we can we can really you know the glucose tolerance test is a conventional test we can get and anybody can do that it's just a matter of understanding the need for it then we do you know then we do you know we're looking at at our lipid profiles and we're not going to get into detail about this but we don't use the conventional lipid profile we use the nmr and we and we look at things uh markers of inflammation that you might not primarily see all the time being looked at like oxidative ldl you know how ldl is oxidized because inflammatory states that you might be in we look at crp it's like rancid fat fat in your blood which isn't good for your arteries you know so we look at other inflammatory markers and these are critical but we do advanced testing where we do a four-point cortisol test as part of you know a profile that will also look at your hormones estrogen progesterone and testosterone and tell us not only what your totals are but going back to a point you made earlier we can actually see if you're a an aromatizer if you know on the tests that i look at i can actually see the pathways in your particular you know physiology that are showing me testosterone being converted to estrogen and are you are you over aromatizing and producing too much estrogen there are some men that naturally are over aromatizers now they may even come to me complaining about you know what i'm having a hard time with erections and by the way doc i've always had this belly fat and i've always noticed i have like some boobs always from when i was a kid and then i do this test and i realized you know i can show them well this is why you you just physiologically for genetic reasons are over and over aromatizer so we can you know there are things that we can do about that and that's natural inhibitors right of aromatase that block that conversion there's even medications that do that like remodex which these are breast cancer to prevent making estrogen in the body exactly there's a lot of tricks out there for us so we do that and so we and so as we work on those things obviously we're gonna be helping them with their erectile dysfunction but these are not simple things to get to and it's not just always a matter of the the little blue pill all right well let's talk about about this patient that you had and how you helped them because i think you know he was this guy named john i don't know if that was on purpose or not then he called him john no no i you know that was actually i always changed names to protect the innocent okay good i'm good what was wrong with john how did you fix his erectile dysfunction so so john is you know sort of your your your classic case that you know that comes to see me you know 56 years old just not feeling where they you know up to par but is being told by this doc after his physical hey everything's fine but he says look everything's not fine you know my erections aren't as great as they used to be i can have them but they don't last as long it's not as pleasurable i'm not sleeping as well i don't have the energy i had and i just get told that yeah it's just part of aging right well he's also at the age where you know menopause is is prevalent and so i see you start to think about these things so with john he's everything we just described he's a little overweight he's a very successful sale you know sales manager he now has a very high-end job with the international corporation doing international sales training spends a lot of time socializing and that means that he drinks a bit too much so we got some extra belly fat we're drinking too much um and you know he's under an enormous amount of stress he wants to retire early he's very uh focused on his retirement and making his bonuses so that he can save tons of money and he's very proud of that and the officers were talking so what's the treatment for him well of course he says his main focus really was the erections and he said you know hindi and kennedy was about to have diabetes you know over and over again so it was just really a matter of just saying look let's work on your lifestyle before we condemn you to a lifetime of you know paying for a little blue pill so so you want to overall feel better and have erections let's start working on it so you know the first thing you know i got my i got all the testing done you know i did a fasting glucose tolerance test and of course he had insulin levels you know way above 40 at you know an hour and two hours which is really you know very significant for insulin resistance he was actually just on the board of being declared totally pre-diabetic his blood his hemoglobin a1c was 5. 6 so 5. 8 is considered pre-diabetic but i told him for a senate also all intents and purposes you're pre-diabetic why do i do that because when they hear when they hear the word insulin resistance they don't know what that is but when they hear the word diabetes they know what that is and that's bad right so i purposely say that i say pre-diabetic all of a sudden i have leverage well how do i fix that doc let's work on your diet so we work on his diet first thing we do is we i put them on you know you know following you know your you know what you've written about so so wonderfully over the years is you know basically a cardio metabolic diet we detox them you know we take out sugars processed foods you know gluten dairy alcohol soy you know basically you know put them on a whole food you know hold vegetable you know i'm sorry vegetable based you know clean diet minus those things just that alone in the first six weeks definitely leads to i feel better i'm losing weight i'm sleeping better the the second thing i tend to go after is stress particularly in a man like that so i tell them by the time you come back to me in six weeks i want you to have established a good stress management program i'll get even more specific and say i want you meditating i want you meditating at least once a day i am a huge believer in the power of meditation to alter every part of your physiology you know and improve it for life um and and actually slow the aging process in many parts of our body most particularly the brain so i really emphasize meditation and stress that's what i do with john so john was a lifestyle change with nutrition first followed by meditation and then uh what else did i do with him oh yeah so i added in some things early on so fish oil his vitamin d was really low vitamin d um was like 17 vitamin d is a very important precursor to all hormonal function so we got his vitamin d up we got his fish oils to reduce inflammation as he lost his weight i gave him an adrenal adaptogen to help him modulate his cortisol because cortisol yep ginseng uh there is some rhodiola and ginseng um and ginseng actually and rhodiola can have an impact on erectile function so i was able to give him that and uh after about nine months he lost weight um testosterone was his testosterone was low it was in the low 400s i we talked about testosterone replacement but i really pushed him on let's get diet let's get stress let's get sleep we did those things and he felt better and by the time we were done in nine months you know with that particular process his um his is his hemoglobin a1c had gone down to 5.