Pioneering Technologies For Lifestyle Based MedicineNutz & Boltz of BHT:

Male Case Studies

Dr. Paul Savage, MDwith

presents

Pioneering Technologies For Lifestyle Based Medicine

o Founder of Power2Practice –

Integrative Medicine EMR

o Founder and Director of Agenixs

(Chicago Medical Practice)

o Practiced Integrative Medicine over 15

years

o Certified in Integrative Medicine at

George Washington University

o Fellow of the University of South

Florida Stem Cell Therapy

o Fellow of the American Academy of

Anti-Aging and Regenerative Medicine

o Fellow of the American College of

Dr. Paul Savage MD

CASE 1 – LOW T CLASSIC

• 55 y/o WM presents with the complaint of stress, fatigue, and gaining weight.

• Goals• Improve sex drive• Improve fatigue• Lose weight

SYMPTOMS

• Fatigue• Weight gain• Low libido• Depression/anxiety• “off my game”

PAST

MEDICAL

HISTORY

PAST

MEDICAL

HISTORY

MEDICATIONS

• None

SUPPLEMENTS

Anti-AgingDHEA 25mg 2 capsules

VitaminsMultivitamins

HeartFish oil

Detox/Prevention

Brain

Gut

LABS

INITIAL TREATMENT

TREATMENT PLAN• Nutrition: Healthy eating &

nutritional counseling

• Exercise: Any!

• Sleep: Monitoring device (Fitbit)

• Mindfulness: 8-minute meditation (Davich)

MEDICATIONS

New• Testosterone Cypionate

200mg/mL 0.4ml injected intramuscularly every 7 days

Maintained

Discontinued

SUPPLEMENTS

Anti-AgingDHEA 25mg 2 capsules

VitaminsAlpha Base without IronVitamin D3

HeartWhey Protein PowderMCT OilOmegaGenics 720

Detox/PreventionEstroDIM

BrainAdapten-all

GutUltraProstatagenOrthoBiotics

RETURN VISIT

• 55 y/o WM presents with the complaints of stress, fatigue, and weight gain.

• Goals:• Improve sex drive• Improve fatigue• Lose weight

• CC: Improved energy, focus, libido, erections, muscle gain, fat loss, improved sense of well-being - “feel great”

LABS

TAKEAWAYS – PERILS AND PEARLS

Testosterone Cypionate (or Enanthate)

Can be given weekly, bi-weekly or monthly

Most men do better on weekly injections

Can be done at home or in office (financial)

Major concerns are PSA elevations, HCT increases and breast tenderness

Done in conjunction with healthy eating and exercise!

PATIENT PRESENTATIONS

CASE 2 - HCG

Goals• Keep exercising and working on my

mobility to obtain full range of motion in all my joints (for injury prevention) and equally balanced strength and health throughout my whole body.

• I'd also like to get my body fat to around 10% and keep it there.

• Maintain healthy testosterone levels to support the goals above.

• Keep or improve sperm count

41 y/o BM presents with goals of improving work outs and gaining more muscle mass.

SYMPTOMS

• Joint aches and pains• Not lean anymore• Fatigue• Insomnia

PAST

MEDICAL

HISTORY

PAST

MEDICAL

HISTORY

MEDICATIONS

• None

SUPPLEMENTS

Anti-AgingTrue Grit Test Booster

VitaminsAlpha JYMJym PostworkoutAnimal FlexBSN NoxplodZMA

Heart

Detox/PreventionWarrior Greens

Brain

Gut

LABS

INITIAL TREATMENT

TREATMENT PLAN• Nutrition: Body builder bulking –

per patient

• Exercise: He is a personal trainer

• Sleep: Monitor

• Mindfulness: 8-minute meditation (Davich)

MEDICATIONS

New• HCG 10,000IU/10mL inject

0.25-0.4mL SQ qAM

Maintained

Discontinued

SUPPLEMENTS

Anti-AgingTrue Grit Test Booster

VitaminsAlpha JYMJym PostworkoutAnimal FlexBSN NoxplodZMA

Heart

Detox/PreventionTongkat AliResveratrolGrape seed ExtractBoronZincEstroDIM

Brain

Gut

FOLLOW UP VISIT

RETURN VISIT

• 41 y/o BM presents with goal of improving work outs and gaining more muscle mass.

• Goals• Keep exercising and working on my

mobility to obtain full range of motion in all my joints (for injury prevention) and equally balanced strength and health throughout my whole body.

• I'd also like to get my body fat to around 10% and keep it there.

• Maintain healthy testosterone levels to support the goals above.

• Keep or improve sperm count levels

LABS

TAKEAWAYS – PERILS AND PEARLS

HCG

More expensive than Testosterone Cypionate

Need to be used daily in the morning

May cause headache, increased blood pressure, peritoneal dull pain, joint aches or rash

Increases sperm count

Usual dose is 250-500IU daily

The older, the higher the SHBG the more HCG will be needed

The older the man, the less likely that HCG will work (needs intact Leydig cells)

CASE 3 – DOSED LATE

• 53 y/o BM seeks an overall health assessment, and to develop healthier lifestyle program.

• Goals• Weight Loss • Increased Energy• Cardiovascular Health

SYMPTOMS

• Fatigue• Weight gain• Low libido• Depression/anxiety

PAST

MEDICAL

HISTORY

PAST

MEDICAL

HISTORY

MEDICATIONS

• None

SUPPLEMENTS

Anti-Aging

Vitamins

Heart

Detox/Prevention

Brain

Gut

LABS

INITIAL TREATMENT

TREATMENT PLAN

• Nutrition: Nutritional counseling & heart healthy diet

• Exercise: Walking

• Sleep: Monitoring device (Fitbit)

• Mindfulness: Relaxation breathing

MEDICATIONS

New• Testosterone Cypionate 200mg/mL 0.35ml

injected intramuscularly every 7 days

Maintained

Discontinued

SUPPLEMENTS

Anti-Aging

VitaminsAlpha Base without IronVitamin D3

HeartWhey Protein PowderMCT OilOmegaGenics 720

Detox/PreventionEstroDIM

BrainSerenagen 2 tid

GutUltraProstatagenOrthoBiotics

FOLLOW UP VISIT

RETURN VISIT

• 53 y/o BM sought an overall health assessment and wanted to develop a healthier lifestyle program.

• Goals• Weight Loss • Increased Energy• Cardiovascular Health

• CC: Weight loss, much improved energy, increased sense of well-being, improved libido

LABS

TAKEAWAYS – PERILS AND PEARLS

Testosterone Cypionate (or Enanthate)

Know when the shot is given (see drop in Testosterone level in this 3rd example)

Lower the SHBG, the lower the dosage

Free Testosterone levels come in handy

PSA generally increases by 10% with addition of testosterone

Growth hormone (IGF-1) generally increases with healthy living, testosterone and health improvements

PATIENT PRESENTATIONS

CASE 4 – OLDER MALE ON T-GEL

66 y/o WM presents with the complaint of "Blood test to ensure I have the right bio-identical hormones.”Goals

• Take advantage of bio-identical hormones to be able to keep my vigor.

• Lose a bit of weight off my belly and pec region.

• Safeguard against cancer, ALS, dementia that plague people growing old.

SYMPTOMS

• Low libido• Fatty breasts, nipple tenderness

PAST

MEDICAL

HISTORY

PAST

MEDICAL

HISTORY

MEDICATIONS

• Testosterone Gel 180mg/mL per day

SUPPLEMENTS

Anti-Aging

VitaminsD3 5000Vit K2Total B Complex

HeartNatural Vit EUbiquinol 100mgCarlson’s Finest Fish oil

Detox/PreventionResveratrol

BrainMelatonin 3mg

Gut50 Billion Probiotic

LABS

INITIAL TREATMENT

TREATMENT PLAN

• Nutrition: Nutritional counseling

• Exercise: Walking

• Sleep: Monitoring device (Fitbit)

• Mindfulness: Relaxation, Tai-Chi

MEDICATIONS

New• Testosterone Cypionate 200mg/mL 0.30ml

injected intramuscularly every 7 days

Maintained

Discontinued• Testosterone Gel 180mg/mL per day

SUPPLEMENTS

Anti-Aging

VitaminsD3 5000Vit K2Total B Complex

HeartNatural Vit EUbiquinol 100mgCarlson’s Finest Fish oilWhey Protein PowderMCT Oil

Detox/PreventionResveratrol

BrainMelatonin 3mgSerenagen 2 tidPhosphotidyl Serine 150mg qhs

Gut50 Billion Probiotic

FOLLOW UP VISIT

RETURN VISIT

• 66 y/o WM presents with the complaint of "Blood test to ensure I have the right bio-identical hormones”.

• Goals• Take advantage of bio-identical

hormones to be able to keep my vigor. • Lose a bit of weight off my belly and pec

region. • Safeguard against cancer, ALS, dementia

that plague people growing old.

• CC: Much better libido, no nipple tenderness, breast size not reducing

LABS

TAKEAWAYS – PERILS AND PEARLS

Testosterone Cypionate (or Enanthate)

Testosterone Gel not monitored well with serum blood testing

High physiologic dosing gives spill over to estrogens

Estradiol is not the only estrogen and is often normal even though symptoms of high estrogen (think Estrone)

Physiologic dosing of gels is important to treat the patient safely

PATIENT PRESENTATIONS

CASE 5 – COMPLEX

19 y/o WM present with history of viral infection 2/2015 after which he started to experience hypersensitivity to tip and ventral of penis, fatigue, loss of testicular and penile size, inability to gain muscle even though working out hard daily, depression, anxiety and erectile dysfunction.

Has been seen by urology who ruled out prostatitis, interstitial cystitis and urethritis. Normal male development which has noted regression of teste size and penile size in past 14 months.

Goals:• Raise my testosterone levels and regain my normal function and be able to build muscle. This is a

priority for me. I do not want to be broken or end up infertile. I want to have a normal sex life and I want to be strong and physically fit.

• Heal my penile tip pain and pelvic pain so I can enjoy being active and being social. I feel uncomfortable with movement. The pain changes in intensity but never goes away. I have flare ups that make me feel I will never heal from this.

• Help me to have normal sleep patterns. I want to have overall good health so I can get stronger and go back to being an athlete. I want to feel good again and have a future of good health.

SYMPTOMS

• Penile tip sensitivity• Peroneal discomfort• Fatigue• Depression/anxiety• Low libido• Erectile dysfunction• Unable to gain muscle

PAST

MEDICAL

HISTORY

PAST

MEDICAL

HISTORY

MEDICATIONS

• None

SUPPLEMENTS

Anti-Aging

VitaminsAlpha Base multi-vitaminFree & Easy Wanderer PlussCorydalisMethyl B ComplexVitamin D 50,000IU

HeartFish Oil

Detox/Prevention

Brain

GutProstate FormulaPolyporus & DianthusOrtho-Biotic

LABS

MRI pituitary: Negative Karyotype: 46, XY Sperm: low viabilityHeavy Metals: Negative

INITIAL TREATMENT

TREATMENT PLAN

• Nutrition: Nutritional counseling

• Exercise: Walking

• Sleep: Monitoring device (Fitbit)

• Mindfulness: Relaxation, Tai-Chi

MEDICATIONS

New• Testosterone Cypionate 200mg/mL

0.30ml injected intramuscularly every 7 days

Maintained

Discontinued• Testosterone Gel 180mg/mL per day

SUPPLEMENTS

Anti-Aging

VitaminsD3 5000Vit K2Total B Complex

HeartNatural Vit EUbiquinol 100mgCarlson’s Finest Fish oilWhey Protein PowderMCT Oil

Detox/PreventionResveratrol

BrainMelatonin 3mgSerenagen 2 tidPhosphotidyl Serine 150mg qhs

Gut50 Billion Probiotic

FOLLOW UP VISIT

RETURN VISIT

• 19 y/o WM present with history of viral infection 2/2015 after which he started to experience hypersensitivity to tip and ventral of penis, fatigue, loss of testicular and penile size, inability to gain muscle even though working out hard daily, depression, anxiety and erectile dysfunction.

• Has been seen by urology who ruled out prostatitis, interstitial cystitis and urethritis.

• Normal male development which has noted regression of teste size and penile size in past 14 months.

RETURN VISIT

• Goals• Raise my testosterone levels and regain

my normal function and be able to build muscle. This is a priority for me. I do not want to be broken or end up infertile. I want to have a normal sex life and I want to be strong and physically fit.

• Heal my penile tip pain and pelvic pain so I can enjoy being active and being social. I feel uncomfortable with movement. The pain changes in intensity but never goes away. I have flare ups that make me feel I will never heal from this.

• Help me to have normal sleep patterns. I want to have overall good health so I can

LABS

MRI pituitary: Negative Karyotype: 46, XY Sperm: low viabilityHeavy Metals: Negative

TAKEAWAYS – PERILS AND PEARLS

Young males with low Testosterone

Consider prior steroid use (including OTC steroids)

Consider Endocrinologist evaluation

Do: Prolactin, Karyotype, Sperm Analysis, Magnetic resonance imaging (MRI)

Do not: Be shy about treating with HCG and if necessary, Testosterone

THE BIG PICTURETAKEAWAYS – PERILS AND PEARLS

Hormone replacement therapy with testosterone implants is superior to oral and topical (both the patch and gel) hormone replacement therapy for bone density (Savvas 88, 92, Davis 95, Anderson 97).

Testosterone pellets were generally well tolerated. (McCullough, AR. A Multi-institutional observational study of testosterone pellets)

Hormone replacement therapy with pellet implantation has an extremely low incidence of side effects (Cardoza 84, Barlow 86, Ganger 89, Pirwany 02) and high compliance rate (Gambrell 06).

For delivering a consistent dose over the long term, pellets are the best option. Pellets deliver consistent, physiologic levels of hormones and avoid the fluctuations of hormone levels seen with other methods of delivery (Greenblatt 49, Thom 81, Cantrill 84 Stanczyk 88).

Testosterone pellet implants release testosterone at a steady rate of 1.3 mg/200 mg implant/day. (Kelleher, S. Testosterone release rate and duration of action of testosterone pellet implant).

Hormones delivered by the subcutaneous implants bypass the liver, do not affect clotting factors and do not increase the risk of thrombosis (Notelovitz 87, Seed 00).

Testosterone delivered subcutaneously by pellet implant is cardiac protective (Sands 97, Worboys 00).

Testosterone delivered by pellet implantation, does not adversely affect blood pressure, lipid levels, glucose or liver functions (Burger 84, Farish 84, Fletcher 86, Barlow 86, Notelovitz 84, Stanczyk 88, Davis 95, 00, Sands 97, Seed 00,Cravioto 01).

The pellets not only prevent bone loss but also actually increase bone density (Savvas 88, Studd 90, Garnett 91, Savvas 92, Naessen 93, Holland 94, Studd 94, Davis 95, Anderson 97, Seed 00, Panay 00).

Testosterone replacement with long-acting Testopel pellets had a lower rate of infection (0.3%) as compared with historical data from the Organon testosterone pellet (1.4–6.8%). The rate of pellet extrusion was substantially lower (0.3%) as compared with historical data (8.5–12%). Patient satisfaction was high and serum hormone values were improved. (Cavender 2009)

THE BIG PICTURETAKEAWAYS – PERILS AND PEARLS

Testosterone pellets

Start with T200mg x4

Increase by 200mg if younger, leaner, more stressed, more active, higher SHBGDecrease by 200mg if older, fatter, less active, more illnesses, lower SHBG

Repeat labs 1 month after first implant

Usual testosterone 5-10mg/day burn rate

THE BIG PICTURETAKEAWAYS – PERILS AND PEARLS

Adverse Reactions

• Pellet extrusion 0.3-12%• Pain at insertion site: 5-8%• Infection at the site of insertion 0.3-6.8%• Nipple tenderness 3-5%• Bleeding at insertion site 0.3-1.5%

THE BIG PICTURETAKEAWAYS – PERILS AND PEARLS

(855) 667-1967

THANK YOU!

Paul Savage MD, FACEP FFARM