Doc Discussions with Dr. Jason Edwards
THIS is the podcast you have been looking for! "Doc Discussions" are just what the title says they are: physicians from a wide range of specialties, talking about relevant, up-to-date medical topics, not to mention tips on habits to help you live your best life. Your host, Jason Edwards, MD, is a board-certified radiation oncologist with a PhD in cellular and integrative physiology at St. Luke's Hospital in St. Louis, Missouri. Dr. Edwards explores not only diseases but also suggests techniques to optimize mental and physical health for a long and good life. Real people. Real advice. Real good. This is Doc Discussions, with Dr. Jason Edwards!
Doc Discussions with Dr. Jason Edwards
Beyond the Bladder: A Urologist's Perspective on Cancer, Treatment, and Quality of Life
What happens when NFL legend Deion Sanders has his bladder removed? How do doctors decide between watchful waiting and aggressive treatment for prostate cancer? And why are testosterone levels declining across the population?
Dr. Nimrod Barashi, a urologist at St. Luke's Hospital, takes us on a fascinating journey through the world of urological health in this episode of Doc Discussions. With his unique international background—born in Venezuela, educated in Colombia, and trained at prestigious American institutions—Dr. Barashi brings a global perspective to common but often misunderstood conditions.
The conversation begins with an in-depth look at bladder cancer through the lens of Deion Sanders' recent diagnosis. Dr. Barashi explains why Sanders required complete bladder removal despite having non-muscle invasive disease, detailing the three reconstruction options patients face after cystectomy. His clear explanation of warning signs—particularly blood in the urine—serves as a crucial reminder that early detection saves lives.
When the discussion shifts to prostate cancer and baseball star Ryan Sandberg's recent death at 65, Dr. Barashi carefully outlines the risk-stratified approach modern urology takes. From active surveillance for low-risk disease to the balancing act between quality and length of life in treatment decisions, listeners gain practical knowledge about this common cancer.
Perhaps most relevant to many male listeners is the final segment on testosterone replacement therapy. Dr. Barashi addresses the apparent decline in testosterone levels across the population, explaining diagnostic criteria, treatment options, and the surprising ways low testosterone impacts overall health beyond just sexual function.
Throughout the episode, Dr. Barashi's patient-centered philosophy shines through—we treat symptoms, not numbers. This approach reminds us that while medical technology continues to advance, the art of medicine remains deeply human.
Have you noticed changes in your urinary habits or experienced symptoms that concern you? Don't wait—reach out to a urologist for proper evaluation. Your quality of life matters, and as Dr. Barashi demonstrates, modern urology offers more options than ever before.
Hello, this is Jason Edwards and this is Doc Discussions. I'm here today with Dr Nimrod Barashi. How are you doing, sir? Good, thank you. How are you? I'm doing? Well, thank you. So you're a urologist.
Speaker 2:Yes, I am, I'm a urologist. I graduated from urology last year at Wash U and came to St Luke's in September.
Speaker 1:Yeah, very good.
Speaker 2:Now tell us about your background. Where are you from originally? So I was born and raised in Venezuela, in South America, in Caracas, and then my parents are actually Israeli, but they came to Caracas in the late 80s and I grew up there, and then I went to medical school in Bogota in Colombia, did six years of medical school like most people outside the US do and in 2016, I came to the US. I went to the University of Chicago, did a couple years of urology research and then I started my residency training. I did a year of general surgery in Chicago as well, at the UIC, and then I came to WashU in 2019.
Speaker 1:That's great and so you know, when people think of Columbia, you think of like this, bogota, this rough town. But my brother-in-law went a few years back to play golf there and he said it was a very nice city, absolutely I mean, at least the years I was there, bogota was phenomenal.
Speaker 2:I mean it was a beautiful city, lots of things to do, it was safe. I really liked it. I mean it was probably some of the best years of my life.
Speaker 1:Yeah, yeah, I've heard it's a nice place. It's a very hilly city too, right yeah?
Speaker 2:it's 2,600 meters above the sea level. Okay, it's very, very high. It's almost like Vail in Colorado, wow. So very, very high altitude, some rain, but very hilly, very nice. And Colombia in general, and Venezuela, both beautiful countries, they have everything you have, you know sea, desert, forest, waterfalls, whatever you want?
Speaker 1:Yes, is Angel Falls in Venezuela. Yeah, yeah, that's great man, the tallest in Venezuela.
Speaker 2:Yeah, yeah, that's great man Waterfall in the world. Yeah, yeah, very cool.
Speaker 1:Yeah, and so it's not easy. You know you had to I'm sure you were at the top of your class to be able to get into University of Chicago is a great school. And then, obviously, Wash U.
Speaker 2:Yeah, I mean I think it was a combination of a lot of hard work, some smart choices, but a lot of people who opened doors for me. I'm very lucky to have met a lot of people who opened doors for me along the way and, yeah, it's been a tough road, but here we are. Yeah, well, we're happy to have you here.
Speaker 1:Thank you. So some things recently in the news. Deion Sanders of course he's the coach of Colorado and you know football player, baseball player Neon Dion recently was diagnosed with bladder cancer and at least in the news reports they said that they removed his bladder. And most bladder cancers are early stage bladder cancers where they do TURBT, where they just go and scrape off the tumor from inside and then that's it. But he must have had an advanced stage disease to have a removal of the bladder.
Speaker 2:Yeah, I actually was able to listen to part of the press conference and from what his doctor said, he had a non-muscle invasive but very high risk bladder cancer, which means it wasn't technically very advanced in such that it wasn't invading the muscle layer of the bladder, but it had some kind of histology or some kind of variant histology that made it a very high risk, and so that's why the decision was made to remove his bladder. I have to assume I don't know the details of it, of course, because that's protected patient information but yeah, most bladder cancers, when they're diagnosed early, they're treated by resecting it in the operating room and then you know some combination of either surveillance or putting some kind of agent into their bladder, whether that's chemotherapy or BCG, which we can talk about too. But yeah, you know, in the setting of a more advanced bladder cancer, like invading into the muscle or other layers of the bladder, removal of the bladder is, you know, the mainstay therapy.
Speaker 1:Yeah, you can have these variants that are not like the typical transitional cell. I don't know if you can have a small cell of the bladder, but something like that, right.
Speaker 2:Yeah, you can. There are other variants that are very aggressive, micropapillary being one of them, plasma cytoid being another one, and there are other criteria to determine whether or not a non-muscle invasive bladder cancer is very high risk. Part of it is the size of the tumor, if it's multiple locations or if it has come back after resecting it. So there are many criteria. So I assume he met one of those criteria to have his bladder removed up front for a non-muscle invasive disease.
Speaker 1:That's a big deal and that's that's a. That's a tough. You know, life can be difficult after having the bladder removed. Um, the um. There's, there's a. There was a guy I worked with named Randall Roland who, uh, created, who pioneered the Indiana pouch, um, when, when he was at Indiana, yeah, and so super nice guy too, super nice guy. But, but there's there's a couple of different ways you can do a cystectomy. As far as reconfiguring a new bladder, right, Correct.
Speaker 2:Yeah, so when you do a bladder surgery or bladder removal surgery or cystectomy generally speaking, let's talk about for males, because bladder cancer happens four times more often in males than females you remove the prostate as well the seminal vesicles in the bladder and some lymph nodes, and then, once you do that, you have to reconstruct the urinary system so that you can plug the ureters in, so the urine can drain from the kidney out somewhere. So there are several ways. One of them, the most common one, is called an ileal conduit, which means getting a piece of bowel and plugging the ureters into that piece of bowel and then bringing that bowel segment to the skin and then bringing that bowel segment to the skin and then the urine would drain continuously to a bag, which can sound very life-altering, but it's also very well tolerated for patients and there's a lot of resources for patients to see, to understand what life means after an ileoconduit. That's the most common one. The one that Deion Sanders got is called a neobladder. A neobladder is one where you use the same type of bowel but instead of bringing it out to the skin, you reconstruct the bladder and you connect it to the urethra.
Speaker 2:There are several, you know indications for that. Not every patient is eligible for having a neoblutter. They have to meet very strict criteria and it can definitely be life altering. He even mentioned that he's incontinent. That's very common.
Speaker 1:So he has leakage.
Speaker 2:Yeah, he has some urinal leakage, which on daytime it happens in about 20% of people, maybe 10, 20% of people. Nighttime incontinence is very common after a neoblatter, up to 40, 50%. And then you have to be willing to catheterize your neoblatter. Bowel, as opposed to bladder tissue, makes a lot of mucus, so you have to be able to remove that as well, kind of mechanically remove it. So, yeah, not everyone is eligible for a Dion Sanders neobladder but yeah, that's another option. And then, as you mentioned, the Indiana pouch, which is literally creating a pouch out of bowel and then bringing either a piece of bowel or the appendix to the belly button and catheterizing through there.
Speaker 1:Is that where you use the ileocecal valve to kind of help, so it's not free flowing in, correct?
Speaker 2:Okay yeah, we call that the Mitrofinov principle, where you bring the appendix up and you catheterize through the appendix. You basically make a tube out of the appendix and use as a channel to catheterize and the channel is continent because of the acetyl valve. Okay, okay yeah.
Speaker 1:Yeah, and then sometimes, if patients aren't surgical candidates, we treat them with an intact bladder and treat it with chemo and radiation as well. Absolutely.
Speaker 2:Yeah.
Speaker 1:So there's several options if you have an advanced bladder cancer. But fortunately most bladder cancers are early stage where you can keep your normal bladder and they just go in and kind of scrape away the tumor.
Speaker 2:Correct. So the way I explain it to my patients is you know the bladder has three layers right it has the bladder lining, then the muscle and then the fat. We make the distinction in bladder cancer between muscle invasive and non-muscle invasive because in the muscle layer we have the blood vessels. So once the bladder cancer reaches that layer it can theoretically spread outside of the bladder. And so for non-muscle invasive bladder cancer, so the ones that are either very superficial or just invade the first layer, you can treat by resecting and sometimes you need to put chemotherapy or some kind of agent into their bladder through a catheter periodically. There are several protocols for that.
Speaker 2:And then when it comes to a muscle invasive bladder cancer, the standard of care is doing chemotherapy first, followed by a cystectomy, and you know the survival after something like that depends really on the stage of the disease, especially the stage at the time of the cystectomy.
Speaker 2:Stage of the disease, especially the stage at the time of the cystectomy. So once you remove the bladder and look at it under the microscope and see how much the tumor is invading into the bladder tissue, you can kind of get an estimate of the life expectancy or five-year overall survival, depending on how deep it goes into the tissue. If there's no tumor after the cystectomy, no tumor left, let's say it got treated by the resection and the neoadjuvant chemotherapy. Survival at five years is somewhere between 85 and 90%. Oh, that's pretty good for a muscle invasive, yeah. And then once you start going up, that number obviously goes down. And then for patients who are not candidates for this surgery, which is a big surgery, you get the trimortal therapy, which is what you alluded to, the resection plus the chemoradiation which brings that five-year survival down to maybe 65%, 70%.
Speaker 1:What's the most common presenting symptom for somebody who has bladder cancer?
Speaker 2:Yeah, so the most common presenting symptom is hematuria or blood in the urine. Right, that can come in two forms. It can be microhematuria, where you have blood in your urine test that your primary care or some other doctor does, or you can have gross hematuria that you can actually see it. Both are concerning. About 10% of people with microhematuria will have a diagnosis of bladder cancer, and when it comes to gross hematuria, that number goes up to 30% to 35%. So it's important to get tested, right. There are guidelines about this, especially for microhematuria. There are several criteria that you use to determine if the patient is low, intermediate or high risk and then, depending on that, you do some kind of testing. But for the most part, and especially for gross immaterials or blood that you can see, the testing for that is twofold. It is a CT urogram, which is a CAT scan with IV contrast, where we not only look at your kidneys but we also look at how your kidneys filter the contrast. So the contrast paints the ureter, which is the tube that brings the urine down to the bladder, and so we look at the kidneys, we look at whether or not there are kidney masses or if there is a feeling defect in your ureters. Concerning for a ureteral mass, we look at whether or not you have kidney stones, we look at the size of your prostate and then the CT scan is not really good to look at bladder. So the second part of the testing is called a cystoscopy, which is a quick procedure we do in the office where we put a small camera through your urethra into your bladder and we take a look directly at your bladder. Right?
Speaker 2:A lot of people you know they disregard blood in the urine for many reasons, whether because they had some kind of symptoms of infection or because they felt like they were dehydrated that day. But a lot of things can cause blood in the urine. It's not only bladder cancer, right, it can be a urinary tract infection, it can be stones, it can be an enlarged prostate in men over 50 years old. But definitely bladder cancer or any type of cancer over the urinary tract are the things that we're looking to rule out. So if you have microscopic blood in the urine in your regular urine test or you see any blood in the urine, you should consult with a urologist as soon as possible.
Speaker 1:Yeah, and, like you said, for those of you out there who kind of aren't familiar with it, the urinary system. It starts with the kidneys that filter the blood and then goes to the ureter, which is the tube that drains from the kidney to the bladder, and then the urethra, which goes from the bladder to either the orifice at the vagina or penis.
Speaker 2:Yeah, yeah, and you know, even people with bladder cancer up to 5% of them can develop disease in their ureters too. Yeah, of them can develop disease in their ureters too. And people with disease in their ureters up to 30% of those can develop disease in the bladder. So if you were ever diagnosed with either one, either bladder cancer or upper tract urothelial carcinoma, which is the cancer of the ureter, the other organ should be also surveilled, you bet.
Speaker 1:And so what's the main risk factor for somebody developing like a bladder cancer in?
Speaker 2:America. Yeah, the main risk factor is smoking or exposure to tobacco smoke, right, the thought being the chemicals that are in the tobacco smoke are filtered in the urine and are exposed in your bladder for a long period of time until you pee, and then over and over again. Right? So all those amines are in your urine, affecting the DNA of the urothelium or the lining of the bladder, right? There are other risk factors exposure to several chemicals used in textiles or concrete. There is some data about Agent Orange for veterans from Vietnam. There's even exposure to arsenic in Taiwan, for example. Is a very common thing? Not very common, but it's one of the known thing.
Speaker 1:Kind of like the aniline dyes.
Speaker 2:Correct and so.
Speaker 1:But one thing that's kind of interesting is, bladder cancer in America is different than bladder cancer worldwide. Here we have transitional cell carcinoma and in other countries you can have squamous cell carcinoma which is thought to be due to I think is it schistosomiasis.
Speaker 2:Oh yeah, so for the most part, bladder cancer is very similar in most countries. Oh, okay.
Speaker 2:But yeah, the one that comes from schistosomiasis is mainly in Africa. But yeah, for the most part it's the same, although the variants are a little different. But yeah, for the most part it's urothelial carcinoma, that's the most common one. Yeah, pseudothelial carcinoma, that's the most common one, yeah, but yeah, and there is also, you know, exposure to nuclear waste. That's a big factor. In fact, there was a law passed recently here in the US Senate to give compensation to certain people in Missouri who lived in certain zip codes and have developed, you know, developed some different types of cancer, including bladder cancer.
Speaker 1:Okay, yeah, that was the.
Speaker 2:Coldwater Creek Correct.
Speaker 1:Yeah, yeah, how about that.
Speaker 2:So they're offering, I believe, up to $50,000 in compensation or to pay any out-of-pocket medical expense related to your cancer. Yeah, they're actually giving out that information to our patients that come to the office with any kind of cancer that is on the list.
Speaker 1:And this was very recently. I think it was Senator Josh Hawley who was the one who pushed it through.
Speaker 2:Yeah, or he was a part of it. I think it was a week or two ago. Yeah.
Speaker 1:And so it's horrible that it happened, but it's great that some of these patients are at least getting some compensation. Obviously, you know they would rather not have to deal with it, but at least they're trying to make amends to some degree.
Speaker 2:Yeah absolutely.
Speaker 1:And then you know the other main cancer. Of course you guys treat kidney cancer as well, but the other cancer that's, you know, the most common with men is the prostate cancer. Cancer, that's, you know, the most common with men is the prostate cancer. And recently Ryan Sandberg, who was a famous baseball player for the Cubs. Of course you know we don't love the Cubs in this town but we do love Ryan Sandberg, great guy all around. But he ended up having metastatic prostate cancer and died at the age of like 65, which is pretty young, I mean, of course you see it. But most prostate cancer, similar to bladder cancer, is a lower risk prostate cancer. Is that right?
Speaker 2:Yeah, when it comes to prostate cancer. You know nowadays prostate cancer doesn't tend to be a lethal cancer in the sense that if it is caught early there are a lot of options to treat it. Obviously, when it presents in someone that young it is sometimes more aggressive pancreas or brain cancer that are very aggressive, very rapidly progressing cancers. Prostate cancer is kind of a slow-growing type of cancer for the most part. Obviously there are exceptions.
Speaker 1:Yeah, yeah, and so typically how it goes is somebody comes in, they get their screening PSA and that's monitored every so often, usually starting at age 50, but there's controversy with that, like all screening, and then they have a bump in their PSA and they find that it's higher, and then they go and see somebody like you.
Speaker 2:Yeah, absolutely. I mean, usually the best way to kind of get your foot in the door with a urologist is having an elevated PSA. Psa should be checked every year. You know, psa in and of itself is kind of an imperfect test. Having it elevated doesn't mean you have prostate cancer, it just means that we have to investigate further. But it's a very important first step and that's how we identify most, if not all, of our patients with prostate cancer.
Speaker 1:Yeah, great screening tool. It's a blood draw and then when somebody has an elevated PSA, usually you take them back and do a prostate biopsy. Is that right?
Speaker 2:Yeah.
Speaker 2:So because of the same reason that I was telling you earlier about being an imperfect test, you know, back when we started using PSA, which the initial studies were done here at WashU, actually by Dr Catalona, when we started using PSA we were biopsying everyone with an elevated PSA and then we realized after a few years that we were over-diagnosing and over-treating patients, meaning we were doing a lot of unnecessary biopsies.
Speaker 2:So nowadays we're a little more selective in whom we take for a biopsy. There are other tests that we can do beforehand. We can do biomarkers which come in urine, biomarkers or blood tests that are a little more specific, which come in urine, biomarkers or blood tests that are a little more specific. Then we have MRI of the prostate, which can tell us the size of the prostate and also if there are any lesions that are concerning for prostate cancer. And then if the suspicion is high enough for what we call a clinically significant prostate cancer, so one that can actually limit your life expectancy, then we say you know what it's worthwhile going for a biopsy and see what you got right.
Speaker 1:Yeah, and then once a patient if they do have biopsy-confirmed malignancy. You got a couple options there, right, correct, and one of which is to do nothing.
Speaker 2:Correct. Yeah, you know, prostate cancer comes in many flavors. You have the low-risk prostate cancer, where the most commonly accepted treatment or recommendation for it is active surveillance, so just keeping an eye on it, not forgetting about it, but doing periodic biopsies and MRIs and digital rectal exam, psas, just to keep tabs on it and make sure it doesn't progress. Then you have the intermediate risk prostate cancer, which kind of opens a couple more possibilities. There is prostatectomy, which is what I do, and radiation, which is what you do, which both are equally effective to treat prostate cancer. The main difference is the side effects of each and we both counsel our patients pretty strongly about those.
Speaker 2:And then there's high-risk prostate cancer where, as long as it is localized to the prostate, the same options remain prostatectomy and radiation therapy plus androgen deprivation therapy, which is basically giving injections to bring the testosterone down to less than 50, which is a very low level. And then there's the option of watchful waiting, which a lot of people don't talk about with their patients. But it's also important to do so because, like I said before, even the aggressive prostate cancers or the high risk, they're still, you know, kind of a slower moving cancer. So watchful waiting is basically, you know, not doing anything unless it becomes metastatic disease, and some people prefer to do that to avoid the side effects of either treatment.
Speaker 1:Yeah, and especially if you're, you know if a patient comes in and you know their wife's pushing them in the wheelchair and you know they don't look like they're going to live, you know, maybe another 10 years. Of course, that's just an estimate, we don't know. But, if their life expectancy isn't great, you know, something like that may be a reason to do just watch or waiting like that may be a reason to do just watch till waiting.
Speaker 2:Yeah, that's probably one of the hardest conversations I have in my clinic with my patients, because obviously you don't want to tell anyone that they have a low life expectancy, uh. But at the same time, the recommendations for PSA screening and for treatment of prostate cancer is based on life expectancy estimations in the US. Right, yeah, and so if a patient comes in with multiple medical issues, that basically you know, means that they're going to have a life expectancy of less than 10 years, then you need to have that conversation as a urologist or as a radiation oncologist with the patients to tell them look, you have to weigh the benefits and the risks of treatment to maybe be able to keep your quality of life as it is for the remaining years of your life. But someone has to have that conversation with those patients, so it can become a little bit difficult, but someone has to have that conversation with those patients.
Speaker 1:So you know it can become a little bit difficult, yeah. Yeah, I mean, the two metrics that we really care about in general with medicine are length of life and quality of life, and you don't want to just totally look at one and not the other. It's I think you need to. You know it's. It's tough to kind of take it all into consideration and kind of make an aggregate decision about what's best for the patient. Of course they help us. We both listen to what they have to say as well.
Speaker 2:Of course, and urology specifically, which is obviously what I do. So I can talk a lot about it more. But urology is a lot about quality of life. We treat a lot of enlarged prostate, of enlarged prostate. We treat a lot of erectile dysfunction, low testosterone. But the mainstay, or basically the thing that we care about the most, is how it bothers the patient right. So if a patient has an enlarged prostate but has no urinary symptoms, we don't treat the number or the size of the prostate, we treat the symptoms of the patient. Same for erectile dysfunction, same for low testosterone. If a patient has low testosterone levels but they don't have any symptoms of hypogonadism, usually we don't treat it right. So we focus a lot on quality of life. That's why we do the same with cancer treatment, despite being cancer and not something benign.
Speaker 1:Yeah, and so you mentioned low testosterone. Actually, a few episodes ago we had Dr Julie Gould on and she's an OB-GYN and she talked a lot about hormone replacement in females. Do you guys have a fair amount of patients who come in for low testosterone? Is that a common thing?
Speaker 2:Yes, we do have a lot of patients that come in for low testosterone, both male and females. Yeah, nowadays it's, I think, more prevalent than it was before. There are reports of this, of how average testosterone levels have decreased in the general population. So, yeah, we do see a lot of low testosterone in hypogonadism patients and even in the setting of prostate cancer in the right patient. I think it's a reasonable thing to do.
Speaker 1:And so what's the level have to be at typically before you treat somebody for low testosterone?
Speaker 2:Yeah, so typically someone with low testosterone would be considered to have a level of less than 300 in two different draws. Usually we recommend testing testosterone before 10 am. That's when usually the levels are more accurate and it's two different draws. Assuming LH and prolactin levels are normal or they respond appropriately to the low testosterone, then we go ahead and treat, assuming the patient has symptoms. Again, because you can have a testosterone of 200 and not have any symptoms. The benefit of treating you may not be there right, but if you do have symptoms like low libido or fatigue or weight gain or erectile dysfunction or even just low energy, then we go ahead and treat you if you have low levels.
Speaker 1:And do? Patients typically respond well to that.
Speaker 2:Yeah, yeah, I mean, it's almost an immediate response. You know there are many ways of treating testosterone. There are injections in the muscle, there are gels that you can put on your skin, there's intranasal testosterone, there are subcutaneous injections. There are now pills for it too, and patients respond really well. I mean it's kind of a life-changing treatment.
Speaker 1:You know, I see the inverse of that when our patients are on androgen blockers for treatment of their prostate cancer and you know they slowly have not, sometimes slowly, sometimes quickly have more and more fatigue, have not sometimes slowly, sometimes quickly have more and more fatigue. And it's a challenge, you know, to get out and exercise and maintain their strength and stamina and muscle loss and hot flashes and the whole bit, and usually when they come off of it they, they feel great, you know, they, they um. Their quality of life, you know, goes up significantly, Um and so. So what level are you shooting for when you give, uh, supplemental testosterone or androgens?
Speaker 1:so we usually shoot for somewhere between 450 and 600 okay and is the top like 800 ish or something like that, like the top of the normal level?
Speaker 2:yeah, yeah, I mean around 800, but you know people are different, right, but yeah, uh, you don't want to, you don't want to overtreat with testosterone therapy either, but around the 450 to 600 level people feel really good.
Speaker 1:That's kind of a sweet spot there, yeah.
Speaker 2:Yeah, very good.
Speaker 1:And then what are the risks of taking supplemental testosterone If you get your levels like four to 600, is that, are there any side effects from that or not really?
Speaker 2:Well, it depends on the type of testosterone you're taking. But let's say you know the typical injection. Obviously injections, high pain, uh, is one of them. Uh, there is, you know, a theoretical risk of um, thromboembolism, right? So clotting, clotting, yeah, so we. So we check uh blood test, like we check uh, so we check a CBC to check the hematocrit every six months to make sure that the hematocrit levels are not too high. And if they are, we actually recommend patients to donate blood to decrease that. But generally speaking, it's a very well-tolerated drug. I mean, the risks of not treating testosterone deficiency are higher. You have cardiovascular risks and obviously all the quality of life, you know effects that we just talked about.
Speaker 1:Yeah, and you know, as we get older, it pays to stay strong. You know you want to have good cardiovascular shape, but you want to stay strong. You know you want to have good cardiovascular shape, but you want to stay strong too. And just getting weaker, um say you, you're, you're a little bit weaker, and then you get pneumonia and you're in the hospital for a week and then you really lose a ton of strength during that time because you're in bed and then it's, it's. You lose it so quickly and it takes a long time to build back up, and so you don't want to start off kind of, you know, a leg behind.
Speaker 2:Yeah, and you know, in the 80s, for example, when you know people were very hesitant to treat testosterone deficiency, the thought being you know, if you give testosterone you increase the risk of prostate cancer. So if you give testosterone you increase the risk of prostate cancer. And the reality is that you know, when you look at the patient holistically, you have. You know, low testosterone is associated with obesity, metabolic syndrome, cardiovascular risk. So there are so many things that can get better if the patient just feels better from their testosterone. Right, let's say you know your fatigue because your testosterone is low so you don't exercise.
Speaker 2:So you gain weight, so you become diabetic.
Speaker 1:And depressed, too Depressed, yeah, psychological depression.
Speaker 2:Yeah, exactly, and you have ED, then you know your marriage doesn't work, and then you know it's all these things that you know make it so that when you treat testosterone, you can increase the patient's quality of life as well as their just overall health.
Speaker 1:Yeah, and for whatever reason, I found that older men really seem that demographic seems to value quality of life you know over length of life more than most other groups. It's just an observation. I'm not really sure why, but it's just something I've noticed over the years.
Speaker 2:Yeah, I mean, I would agree with that, I would agree with that, and so they take a really sensible approach to things.
Speaker 1:typically, you know, and so do they know, what's causing the lower testosterone. I'm sure there's some hypothesis out there, but is it something in the environment or it could be environmental exposures.
Speaker 2:I mean some people who take testosterone replacement for, let's say, exercising in the past. That can have some effect in their pituitary. You know access and all of that. So that could be one of the reasons. Environmental factors definitely a reason, you know.
Speaker 1:Yeah, I know the the bisphenol A was a big deal, and so now when you get an algin bottle or whatever, it'll say BPA free on it, and so that was something. It was actually a guy from the University ofouri who was all over that, but they found that these microplastics were causing um, uh, I, I think they were it was. They were able to show in fish that they were able to get them to like switch, uh, like physical sex, uh, but I be wrong on this, but I think that's what it was Um and and, but it was also um, hypothesized to cause lower testosterone, um, and so get your, get your water filter.
Speaker 2:Yeah, get your Brita yeah.
Speaker 1:Um well, Nimrod, we're, um, we're so happy to have you here on campus. It's a pleasure to work with you. All your patients love you. You're a big hit. Oh, thank you, and if people want to get a hold of you, the number at the office is 636-685-7830.
Speaker 2:Perfect. Yeah, we're at the DOC building, second floor, suite 24B. Perfect Thanks, nimrod.
Speaker 1:Yeah, thank you. Thanks for having me.