# 155 | Hormonal Triple Whammy | Kyle Gillett, MD

Jan 25, 2025

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About the guest:

Dr. Gillett enjoys providing holistic individualized care to his patients. His practice includes preventative medicine, aesthetics, sports medicine, hormone optimization, obstetrics and infertility, integrative medicine, precision medicine including genomics, and aesthetics. He believes that each human is a unique creation that requires attention to their body, mind, and soul. He uses shared decision-making and an evidence-based approach. He firmly believes “food is medicine” and “exercise is medicine”. Dr. Gillett describes the “7 pillars of health”: exercise, diet, sleep, stress, social, sunlight, and spirit. These are more powerful than any medication or supplement. He enjoys spending time outdoors on the farm with his wife, two sons, daughter, and wolfhound.

Kyle's Credentials:

Dr. Kyle Gillett is a dual board-certified physician specializing in family medicine and obesity medicine.

He earned his medical degree from the University of Kansas School of Medicine and completed his residency at Cox Family Medicine Residency

Episode summary:

Kyle walks me through the details behind: hair loss, BPH (benign prostate hyperplasia), and low T, what we can do to keep it from happening or stop it, and his perspective on choosing between finasteride and dutasteride....two of the major players in solving the big 3.

Key Points:

General recommendations for older m
1. once a week 1mg dutasteride is a good preventative program (hair and prostate) with limited side effects (sunflower lethicin )
2. Low dose tadalafil EOD or daily
3. TRT if needed and risks (cancer) are low
Hair loss regiment ( 3 layers)
1. anti androgen (dutasteride)
2. growth agonist (minoxidil)
3. micro needling
Big 3: hair loss, prostate growth (and cancer), and low T. Related?
People with insulin resistance, higher IGF-1, more pronounced metabolic syndrome (pre-diabetes, type 2 diabetes) are more prone to issues
Metabolic syndrome and sleep apnea are the two leading causes of low total testosterone (but not necessarily causing low free testosterone)
Free T and DHT matters more for athletic performance and body composition
Total T matters more for how you feel, and for delivery of androgens to the prostate (growth)
Several different types of 5 alpha reductase enzyme; finasteride and dutasteride have different effects on each which is why they can have different effects.
It mostly about the ratio of testosterone plus dht vs estrogen. If the ratio changes you are more likely to have symptoms of high estrogen
Free T = calculated with total T and SHBG (tightly binding) and albumin (loosely binding)
Free T should be 2-3x lower than estrogen (in normal, not same units). If 4-5 lower estrogen too high.
free t of 15 ng/dl; estrogen pg/mil of 45 (45/15=3)
Free T usually listed as ng/dl (0-50). Can be pg/mil.
Estrogen usually in pg/mil
When on dutasteride or finasteride, have to watch the ratio more closely because the lower dht makes you more sensitive to higher estrogen.
1-2/x week dose of dutasteride will decrease DHT but increase testosterone and estrogen.
SHBG. Why does it reduce free t? SHBG is a good thing unless you have a low free T
As long as free t is 12-15 ng/dl, then the higher the SHBG the better. Helps with stability, metabolism, and delivery to tissues…correlation with longevity.
More SHBG: happens when T is low, when estrogen is high, when insulin is low.
long time endurance athletes: years with low insulin levels due to long exercise…the bodies of such people gets stuck in the high SHBG mode.
Mostly it is better to improve free T by increasing total T rather than reducing SHBG
However, a few things makes sense to do: take boron if deficient. Dates. Raisins.
Try pre or inter workout carbs if you are normally a low carber. It will stop you from having very low insulin but won’t cause high insulin due to the exercise. Insulin peaks can lead to insulin resistance but dips in insulin lead to high SHBG.
SHBG is a sort of buffer system. It keeps the testosterone in check without losing it but available when needed.
The ratios are what matters most but the absolute levels can have an effect. Very high estrogen will lead to high platelets (blood clots). Taking a lot of T will lead to high estrogen which can cause a problem despite the ratio being good.
If body fat is normal: male: 10-22% ; female: 17-33% - less likely to have high conversion of t to estrogen and dht when taking replacement doses of T.
2/3rds of Americans have metabolic illness (maybe 90%, really). “Overweight and obesity epidemic”. Fasting glucose over 100 or fasting insulin of 7 or over.
CRP highly correlated with risk of heart attack and stroke.
Oral testosterone replacement therapy is coming and helps with visceral fat.
TRT replacement can be useful even temporarily even if just above the low end of normal.
TRT replacement therapy is not necessarily forever. Can be used to get out of a doom loop
Rule of thumb: 99% likelihood of getting back to baseline T if no damage. Testicles need to be the same size. If there has been shrinkage, can get back. If starting at 300, can get back. If starting at 300 10 years ago, then get back to 250 without T medication.
A person with moderate total T but very low free T due to obesity would be helped by losing the extra body fat. But that letting feels so bad (low mood, low energy, hates working out) that TRT can help get that person over the hump of feeling better to make progress on the fat loss and enjoying workouts more. Then plan to stop the T once the fat is down and the muscle is up. Natural total T will be about the same, maybe a little less, but free T will be much higher.
ED is the canary in the coal mine. Plaque in arteries mean plaque in blood vessels leading to penis (and brain, etc).
PDE5 is the enzyme that degrades NO. It increases significantly in older people. So NO does last as long. Viagra and Cialis stop the PDE5 action to make NO last longer so the erection lasts longer and blood vessels in the body are relaxed longer. But more NO is not better unless low. The body adapts to these drugs so they don’t work as well if taken all the time.
Best to slightly inhibit SDE 5. Take cialis 2.5mg EOD or 3 days per week.
Cialis also helps with BPH by relaxing the vessels that allow more pee flow. Reduce nighttime peeing.
Gold standard for improving ability to pee with BPH: Alpha blockers (flowmax et al). Can have significant sexual disfunction issues. Alphazosin has less side effects. Also helps with kidney stones.
5 alpha reductase inhibitors— stop DHT causing growth in prostate. Lock the growth in prostate growth and even reduce the size. Good for hair, skin, heart. Maybe a higher cancer risk.
Prostate Surgeries are getting better for preserving sexual function.
Medical management vs surgery is a hard question. Individual due to varying side effects sensitivity.
Should interrupt the natural growth of the prostate. Lifestyle and medical interventions can help.
5a reductase for prevention is tricky. If been on finasteride for a long time with little prostate growth and a low PSA, don’t change. If starting later in life, and PSA is not low, then there is a risk of high grade cancer. Similar to risk of TRT of birth control — not extreme but scary.
No post dutasteride syndrome. Most common side effect is feeling like having low T even when T is not low. But avoids issues with specific to nervous system or pubic skin. 1-2 capsules per week for hair rarely causes side effects. More might be needed for prostate.
Post finasteride syndrome is 90-95% in 20-30 year olds due to disruption of ongoing maturation in neurological and sexual systems
Hair loss regiment ( 3 layers)
1. anti androgen (dutasteride)
2. growth agonist (minoxidil)
3. micro needling
General recommendations for older male athletes
1. once a week 1mg dutasteride is a good preventative program (hair and prostate) with limited side effects (sunflower lethicin )
2. Low dose tadalafil EOD or daily
3. TRT if needed and risks (cancer) are low

Related episodes:

Episode 67 | Hormone Health for the Older Athlete | Kyle Gillett MD

Episode 134 | Testosterone Envy | Rick Cohen MD

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