Season 3, Episode 9: Optimizing Prostate Health and Boosting Testosterone Naturally with Dr. Geo Espinosa

Evelyne: Remember, you can find the entire transcript and video of the show on our website, podcast.designforhealth.com. Let’s get into today’s show. Dr. Geo Espinosa is a naturopathic functional medicine doctor and leading authority in integrative urology and men’s health. He’s also a board-certified acupuncturist and certified nutrition specialist. Serving as a faculty member in holistic and integrative medicine in urology at New York University Langone Health, he’s also a faculty member at the Institute for Functional Medicine.

A dedicated researcher and prolific writer, Dr. Geo has contributed significantly to the field with numerous scientific papers and books, including the bestselling prostate cancer book, Thrive Don’t Only Survive. He’s the Chief Medical Officer at XY Wellness and shares his knowledge through his popular website, drgeo.com, and his podcast, The Dr. Geo Podcast. So, Geo, thank you again for being here.

Dr. Geo Espinosa: It’s my pleasure. Thank you for inviting me.

Evelyne: We haven’t done a show specifically on men’s health, so this will be great, and I am a little nervous. I just took GABA and L-theanine in chocolate form. I was reviewing my herbal medicine notes last night on the urinary system, and I reached out to some of my male colleagues for questions. Then now I have so many questions that we could spend a whole semester going through these. So, I will try to focus on some questions that we most commonly get from practitioners, but first of all, how did you get so passionate in this field?

Dr. Geo Espinosa: I always say the field chose me. I didn’t choose it. So, when I was doing my final years as a naturopathic doctor, as a student clinician, for some odd reason, I kept seeing a lot of men and they kept requesting to see me. So, I did more prostate exams than anyone else. At the time, I was still hesitant to specialize because the philosophy, right? Naturopathic medicine, you don’t treat diseases, you treat people. But then I kept seeing more men. Then I developed an opportunity to work with a urologist here in New York, in Upper West Side, and he was so enthusiastic to learn what I had to offer.

I was so enthusiastic to learn what he did as a medical urologist. I just became fascinated with the urological system and even more so with the male reproductive system, things like the prostate and testosterone as a chemical and erections and penises and maybe as a reflection of odd character of mine of some sort, but I became fascinated with it. In that practice, I kept doing more and more prostate exams and really knowing what I was doing, knowing what I was looking for. Then I got the opportunity to do what I call my internship fellowship at Columbia University Department of Urology under Aaron Katz. I was there for five years, and I was just immersed with all things urology.

Again, I was in the OR with some of these surgeons, removing prostates, and it was just fascinating. Then I was with the guy with the erectile dysfunction guy and what he did for it, I was like, “Wow, this is amazing.” The guys that did TRT and even urinary problems, I was like, “This is amazing.” I became immersed and then I got the great opportunity to be at NYU Department of Urology now for 15 years. It took a life of its own. I’ve never deviated from that focus since. Although there were many times in the beginning where I thought maybe I should just because no one knew me.

While I was employed and it was good, I still needed to have my keep there in the department and at least bring in as much as I’m worth or my salary or something. It wasn’t the case, but I stuck to my guns, and I just became even more and more curious about the field. Here I am now over 20 years doing the same work.

Evelyne: I love it. I love your enthusiasm. It’s contagious. So, let’s talk about testosterone first.

Dr. Geo Espinosa: Testosterone, yes.

Evelyne: Then prostate health, prostatitis, prostate cancer, and BPH. So, first, I’d love for you to give us an overview of how and where in the body testosterone is made and where that process might get interrupted.

Dr. Geo Espinosa: Great question. Partially because I have an 11-year-old son. He’s soon to be 12. You can see that he’s developing some testosterone, but I know that it’s not from his testicles yet. It’s mostly from the adrenal glands. So, testosterone is in men, women make it too, is made in the testicles, particularly in the Leydig cells of the testicles. That’s about 95%. About 5% or so is made in the adrenal glands. Young kids when they are at their pre-puberty stage, they’re making it primarily in the adrenal glands. So, my son, his voice is not cracking yet. He does have some attitude. Yes, he does. He does have some attitude, but he has some hair underneath his arms and pubic hairs.

Along with the attitude, you can see that in a little bit of a little something, a little shade going up there, which will become a mustache at some point. You can see he has some. So, most of his testosterone right now is from his adrenal glands. Eventually, when he reaches puberty, then he’ll start making way more from his testicles and from the Leydig cells and then you’ll see even more change and growth in that. I’m not looking forward to that, but yeah, that’s pretty much where it’s made. It’s a bit of a process of making testosterone because it starts in the brain in the hypothalamic pituitary gland where the hypothalamus creates a gonadotropin-releasing hormone, stimulates the pituitary gland, and then from there, you have luteinizing hormone and follicle-stimulating hormone.

FSH stimulates the production of sperm cells, and LH is the main contributor that attaches to receptors in the testicles, primarily in men and stimulates the production of testosterone. Within the testicles, I don’t know, we don’t have to get too much into the weeds, but it’s very interesting. So, it stimulates the receptors there, and then there’s a process until it gets to the mitochondria for the production of testosterone to occur. So, it’s not as simple receptor cells, testosterone production. There’s a little bit of a process there that requires certain nutrients and things to create testosterone in the Leydig cells. So, we’ll leave it there before we went out of time, and I definitely want to get into some possible natural solutions to helping men with testosterone or whatever urological function we’ll discuss.

Evelyne: Yeah, absolutely. Actually, since you brought it up, what are some of those nutrients that the Leydig cells do need to make testosterone?

Dr. Geo Espinosa: Very interesting. So, chronic inflammation, we know that it contributes to many diseases, but it also inhibits the production of testosterone. So, one of the nutrients that at least has been studied, at least has a couple of papers on it, I should say, that recommends things like ginger, so ginger extract or ginger. So, these are things that you don’t think from a naturopathic perspective. Why would I get ginger for testosterone? Well, ginger actually seems to help at least in some studies with that, and just by lowering, not directly, but by lowering inflammation. Of course, one can extrapolate and say, “Well, maybe curcumin, but other anti-inflammatories as well.” Maybe, I don’t know, but certainly ginger has been looked at, at least in one review, very good study.

Another nutrient that’s important for the whole process to occur in the mitochondria is actually vitamin A as well. Vitamin A helps that process occur very tightly. So, mitochondrial health, very important for many things. I think that we will all agree that mitochondrial medicine is an important thing and across the board for many reasons, longevity, et cetera. Certainly important to have good mitochondrial health for testosterone production, and I think vitamin A and ginger are two of the things that I like to use for that specific… It’s not the only thing I use, but for that particular.

Evelyne: Very interesting. Thank you. So, when a patient comes to see you, what are the lab markers you’re looking for other than total testosterone, which is likely all that they’ve maybe had tested?

Dr. Geo Espinosa: That’s a fabulous question and here’s why. What I’m noticing, Evelyne, is the following. So, a lot of testosterone clinics, they’re just looking at total testosterone and that’s it. If your total testosterone is… I don’t know, whatever. So, the normal value on most labs from most labs is about 300 nanograms per milliliter to 1,000 nanograms per milliliter roughly. So, if you’re anywhere in between that, that’s good. Then some people are saying, “No, no, no, optimal is 600.” There is no good evidence. I say this because I used to say, “Well, I want my patients to be between 600 and 800.” The truth is that there is no good evidence to show that that is optimal.

The most important thing that a man can do, I want free testosterone to be 2 to 3% free testosterone, period, end of story. Almost irrelevant to what the total is. So, I have patients just recently, by the way, because I always thought, “Well, you need at least 350 total to get enough free.” I’ve seen that. I know many patients who are at 350, but they have like 2% free testosterone or more. Just saw a patient, 280, a lot of free testosterone. They’re not symptomatic, no libido issues, none of that. So, I think that we need to investigate that a little bit more, but from my clinical experience, if they’re not complaining about sexual issues, abnormal fatigue, cognitive decline, low libido, which most of them will not complain if they’re have enough free, then I’m not going to treat the total.

I don’t care to treat the total. If they don’t have enough free total, then that’s what I’m looking to do. So, that’s that. Then the other component is estradiol, right? So what matters is some people say, “Well, high estradiol is bad for men.” What I would say is the ratio between total testosterone and estradiol is what we’re looking for. Estradiol is a very important hormone for men as well, obviously considered a woman’s hormone, but it’s a very important hormone for men. It’s important for cardiovascular health. It’s important, Evelyne, you may not know this, but you need enough estrogen or estradiol for libido in men, not only testosterone. So, men with low estradiol actually have low libido, so bone health, many things.

So, what you’re looking for there is ratio. So, I like my ratio to be around 20 to 1, total to estradiol roughly. If I had to write a paper on that, I don’t know that I’ll have good references, but some of the experts that I listened to plus my experience dictates that. I like just the absolute value of estradiol to be 10 to 20 nanograms per milliliter roughly. So, I’m looking more towards the ratio, but if it’s as an absolute value, I’m looking between 20 and 30. Along those lines, I think the audience is going to appreciate what I’m about to say now, which is hopefully they appreciate the whole thing. But what I’m about to say is the following. Clomiphene is oftentimes used as a drug to stimulate the production of testosterone, and it does that because at the hypothalamic pituitary gland, right?

Just more LH. I’m sorry. Yeah, that’s exactly. It’s a SERM, right? So it blocks the receptor of estrogen in the brain and then that makes the more LH production and so forth and then eventually leads to the testicles and you create more testosterone. What happens in that situation is that clinically they present with, yup, testosterone is good, 800. Maybe free is okay, but estrogen is low. So, they would say, “Yeah, my numbers look good, but I still feel like crap,” or at least their libido is still low. That’s because their estradiol levels, they go down too much.

So, aromatase inhibitors where you try to inhibit the production of estrogen in men. Clomiphene is a good drug if there’s a male infertility issue along with low testosterone, but I try not to use those drugs much unless there’s a male infertility issue and I don’t use a lot of aromatase inhibitors. Even if the estrogen is a little bit higher than normal, I’m really looking at the ratio that should be 20 to 25 to 1 roughly. Does that make sense?

Evelyne: Yeah. I have so many follow-up questions.

Dr. Geo Espinosa: I know. I think I just said so much.

Evelyne: It’s okay.

Dr. Geo Espinosa: There should be a lot of follow-up questions, but go ahead. I’ll let you lead the way.

Evelyne: So does the same thing happen with giving testosterone replacement therapy where if you’re giving so much, it throws off those levels of estradiol?

Dr. Geo Espinosa: Yeah, good question. Look, sometimes in some clinics, they give total testosterone and right away they give them aromatase inhibitors in some of these male clinics. I don’t agree with that approach at all for the reasons that I just highlighted that you do need estrogen. Depending on how the patient is monitored on TRT, again, sometimes they’re not monitored well, I see. But if they’re monitored closely, then it’s a matter of making the adjustment to the TRT in a dosage that’s used where maybe testosterone is 900.

Okay, maybe the estradiol is 40. I’m okay with that ratio. Actually, 900 to 40, though it may seem high. So, I wouldn’t treat it with aromatase inhibitors necessarily. So, it all depends what happens. So, once you get the testosterone and what happens to it, does it convert a lot to just DHT or estradiol or it’s doing what it’s supposed to do? Attaching to receptors and DHT is a fine thing as well. That’s the other thing that happens with testosterone. It can convert to DHT.

Evelyne: I want to back up one moment to the sex hormone binding globulin. You said those levels can be too high. What’s the range that you look for for SHGB?

Dr. Geo Espinosa: The range that I look for is around 30 to 50, I believe. Sometimes I get my ranges in my head. That’s why I have always a chart, but it’s between 30 to 50, but mostly rather than saying, “Well, the SHBG is such,” I’m really looking at free testosterone, and I let that dictate how low I like my SHBG to be.

Evelyne: Got you. Then you just mentioned DHT, which stands for dihydrotestosterone, right?

Dr. Geo Espinosa: Yes.

Evelyne: What is the benefit of measuring that and in what clinical situations would you want to lower that? How do you use DHT?

Dr. Geo Espinosa: There’s some things that are a little bit controversial in medicine, of course, and one of them is this fear of DHT because it will increase the size of the prostate. So, DHT is a much more powerful androgen than testosterone. So, it attaches to the receptors a whole lot stronger and it sticks to that receptor longer than just testosterone. So, it’s known for things like baldness and prostate enlargement. The problem is when the DHT is way much higher than testosterone, and that ratio is also off. It’s a ratio that I like to be 12 to 1, total testosterone to DHT. When that’s imbalanced, because there’s too much 5-alpha reductase enzyme activity, that’s the enzyme that converts testosterone to DHT, then there’s a lot of conversion.

DHT goes up really high. So, the group of drugs that are available are called 5-alpha reductase inhibitors, these are like finasteride and dutasteride. They’re again another set of drugs that I never prescribe. I think these drugs can do more harm than good. Some people take it in the form of Propecia, which is a lower dosage for hair, just keeping hair. I’ve just seen too many feminization of men where they lose their libido and all kinds of things. Sometimes it leads to post-finasteride syndrome where they have these side effects, even depression where they can… Post-finasteride syndrome, I think I’m close, where they have fatigue and they don’t feel well and they don’t have libido and so on.

So, that happens to about 1% of the population that takes these drugs. So, summary, lower DHT is not necessarily the evil hormone, just like many things are not evil. Just like cortisol is not always evil. You need cortisol. It all depends on the numbers and ratios. Same thing with DHT. So, that group of drugs, 5-alpha reductase inhibitors, I don’t think that’s a good idea for most men.

Evelyne: So what about when you do seesaw palmetto in a formula? Will that help?

Dr. Geo Espinosa: Yeah, so the question that we are trying to address is how do we reduce DHT naturally for purposes where the DHT is too high? If the purpose is to decrease DHT, now, I’m not saying DHT is bad for the prostate. I’m not saying this whole notion that let’s just reduce DHT to reduce the size of the prostate. That’s another approach. That’s not the right approach. That’s what’s done medically, but I don’t recommend these drugs for urinary problems related to the prostate, right? To promote prostate health, saw palmetto in a formula is fantastic, no problem. To lower DHT, if that is the goal, then I would recommend just a standalone saw palmetto at a higher dosage.

Evelyne: Got you. Good to know. We will get into some of those other prostate things a little later on. I do have more questions about, well, testosterone metabolism. So, I know more about estrogen metabolism in women and using things like DIM and calcium-d-glucarate and sulforaphane, et cetera. I just don’t know as much about testosterone metabolism. So, are you measuring that also, and were you saying earlier that you don’t use things like DIM and chrysin or you do in men?

Dr. Geo Espinosa: So I use DIM and chrysin or I would use DIM and chrysin if the estrogen levels are too high. So, I’m not trying to super metabolize testosterone. That takes care of itself in men. You have enough high, it’s good, or you have enough free, it’s good. We don’t have to worry about that. I’ve never seen a scenario where, wow, there’s just way too much free testosterone. We need to lower this. It’s different than too much testosterone in women, for example, or too much estrogen in men. If there is a case where they’re not metabolizing the estradiol, then DIM and chrysin is perfect to prescribe there.

Evelyne: Got you. You also said something interesting about the drug in testosterone and that it helps with infertility. When it comes to testosterone replacement therapy, I thought that can impact fertility because it reduces sperm production. So, can you talk about-

Dr. Geo Espinosa: That’s correct.

Evelyne: … how those are different?

Dr. Geo Espinosa: If the goal is that the person wants to increase their testosterone and also increase their free testosterone and they have no intentions of being fertile or having kids, then TRT, it’s right. It’s a fine approach in most men. In a situation where they are interested in fertility, then TRT is not what you want. You want clomiphene in that scenario and you have to be aware that the libido may not be optimal, but it may help with fertility. Why? Remember, so working in a hypothalamic area, and it’s increasing not only LH but FSH. With more FSH, you make more sperm cells.

So, that’s the reason why. So, you get a twofer, right? You get more testosterone, but you also get more follicle stimulating hormone production, which helps with sperm cell production. So, that’s why it’s the drug of choice when medical approach is the way that they choose.

Evelyne: This is really interesting because I really feel like testosterone replacement therapy is gaining popularity, especially among younger and younger men.

Dr. Geo Espinosa: That’s right.

Evelyne: I don’t know, they’re not aware of some of those risks. Are there other negative potential effects?

Dr. Geo Espinosa: No. I just wanted to confirm what you just said, that a lot of younger men are not looking at the bigger picture. They just want whatever they want. They want more muscles or they’re trying to feel more manly or whatever. I mean, if you get off TRT, can you become fertile? Yes. But then you’re going to go to a dip, right? Until your body’s able to produce it on its own. There’s a way of transitioning with the use of HCG to stimulate the cells.

So, sometimes what they do, and I don’t have this level of experience, but what some practitioners do is they do TRT with ACG simultaneously, so that you can still produce enough testosterone from the testicles as well as the TRT having that benefit. So, the STG acts like glutenizing hormone like LH and stimulates the cells of the receptors of the Leydig cells who produce testosterone. So, that’s the approach that some take for fertility.

Evelyne: Is there also any risk or any other risks like with prostate cancer, we give androgen deprivation therapy, right? I don’t know if that’s always the case. So, is there some negative effect with actually taking testosterone down the road?

Dr. Geo Espinosa: Now you’re asking the zillion dollar question, and I’m going to try to answer that as simply and as efficiently as possible because that alone, it’s been a very controversial scenario. The way I would answer it is like this, and it’s very important that the practitioner knows this. By the way, I’m not promoting TRT or against it. I am promoting optimal male hormones or male hormone levels. That’s what I’m promoting, whether the natural approach, which can work very well or TRT. Okay, so let’s start there. Number two, having optimal hormone levels, despite it being TRT or just naturally, does not cause prostate cancer. So, the practitioner does not need to worry about optimal hormone levels, male hormones and prostate cancer development.

That is even despite if there’s a family history of prostate cancer. That doesn’t mean that that person will not develop prostate cancer. They might, but it’s not connected. Even after a person is diagnosed with prostate cancer, then depending on their situation, some of them go on TRT. If it’s low risk, if it’s well managed, if it’s treated and properly managed, they go on TRT successfully. There’s research and data to support that. The people that go on androgen deprivation therapy are those with very advanced disease.

I tell you, the notion of androgen deprivation therapy as a treatment for prostate cancer is very controversial and there is some technology available now including some artificial intelligence technology that helps the practitioner to decide if the patient will benefit from androgen deprivation therapy or not, from an advanced prostate cancer scenario. So, testosterone treatment or optimal testosterone levels before prostate cancer diagnosis, not associated. After treatment for prostate cancer, we still want optimal testosterone levels. In men with advanced prostate cancer, the treatment is ADT, controversial a little bit, but it seems to be helpful in some cases. It’s not the testosterone.

It’s the androgen receptors that seem to, in some cases, it seems to signal the development and progression of prostate cancer. So, it’s not testosterone, it’s the receptors. So, the idea is if you take away the testosterone, there’s no receptors. That’s the idea. I think that that area is going to develop and it’s going to go in a different direction, and this is research out of Hopkins, including using testosterone therapy at very high dosages along with androgen deprivation therapy. It’s called that bipolar androgen therapy. So, what that would do is not have as many receptors develop, just enough receptors. So, now the androgen deprivation therapy can actually work.

So, high levels of testosterone will actually help, not only does the math feel good, but it may help the ADT done simultaneously, ironically, to have regression of prostate cancer. That’s not available yet for clinical use, clinical approach, but they’re studying it.

Evelyne: Very interesting. Thank you for that thorough answer. Really appreciate that. Before we fully move on to prostate cancer, I do have one other question or a series of questions about testosterone, but ways to boost testosterone naturally, maybe some lifestyle measures and then some nutraceuticals. I know we see ingredients like tribulus, tongkat ali, horny goat weed, things like that. Can you address some of those?

Dr. Geo Espinosa: Yeah, those horny goats, I tell you.

Evelyne: What a name, right?

Dr. Geo Espinosa: So tongkat ali, ashwagandha, and fenugreek seem to be my top three for testosterone production. Once again, very specific for that function. The way a naturopath or a functional medicine doctor would function is that I don’t think I need direct research to show this helps with that. Again, I use ginger. I use vitamin A, right? So I use ashwagandha. The benefit there is that it can reduce too much cortisol, right? Cortisol interferes with production of testosterone. So, that combination is really, really useful. So, there’s lifestyle things as well, but those are the botanicals. I would add zinc to that. I would add boron to that combination and magnesium.

Evelyne: Great. Then just a few lifestyle factors, just really quick.

Dr. Geo Espinosa: Lifestyle factors. By the way, you can increase testosterone by 300 points or so. I’ve looked at it. I’ve studied it. I’ve had some data on that, so clinical data. Some people just want the injection and keep it moving. It does require a little bit of work. So, maybe sleep a little better. So, you make most of your testosterone in REM sleep, stage four. So, if you don’t hit REM, it’s going to be a little bit more difficult. So, that’s that. So, sleep is important, right? At least hitting REM, not necessarily you have to sleep nine hours a day, but are you hitting REM? Sometimes some people can reach that in five hours. I’m not. So, you had to hit REM. Exercising, you have to lift weights and you have to focus on bigger muscles like your back and legs and lower extremity that is, right?

You find a way, I don’t know. I post some of the exercises on social media that I do. Oh, be careful with your back. Oh, my God. You got to break your back. So, there’s a lot of things like that that are may or may not be true. Bottom line is then find a way of working out your legs that are safer, whatever that is, your lower extremities. But that’s important for that. I’ll tell you how that works is I’ve looked at it and one of the thought leaders in testosterone, I remember him tweeting, he tweeted something that said, “To be clear, exercise does not help increase testosterone.” I said, “Oh, shoot. So, I need to look into this.” Here I am saying do this. So, that was a very general statement. What kind of exercise? What’s the prescription, right?

So I’m like, “There’s probably a prescription, a prescriptive approach.” So here’s the deal. Weightlifting, and I didn’t say this when we were talking about how testosterone works, but maybe I’ll say it now, not only do you need that pathway to occur smoothly, so from the brain, the hypothalamic-gonadal axis needs to work smoothly, but also the receptors need to be healthy and you need enough receptors. Receptors are very important. That’s another thing, you see men with high testosterone and all the levels are fine, but I don’t feel receptors. Now, there’s no clinical way of measuring receptors that I know of anyway. The only way is through a biopsy and things.

No one’s going to do that. But one can assume if all things look good and they’re still feeling a certain way with hypogonadal, then maybe the receptors. So, the way weight-resistant exercise works is by stimulating these receptors partially. Let’s just say you lift weights and you do arms and you do any weightlifting. In order to increase the actual production of testosterone, then now you have to be a little bit more specific to back and lower extremities, like bigger muscles, and it’s somewhere like 10 repetitions and two-minute rest times six. There is some research to indicate that if you do something similar to that, then testosterone does go up, not only initially, but at least within 24 hours as well. So, summary, exercise, how it works is both. Androgen receptors, they get healthier, you make better, and total testosterone goes up.

Evelyne: Awesome. Thank you for that. I love that you’re sharing the nuances around these different topics too. So, let’s dive a little bit more into prostate cancer. Prostate cancer is the second leading cause of cancer death in American men after lung cancer. I found this interesting too, often have double the risk. They also tend to get diagnosed younger and it tends to be more aggressive. So, it is a major issue. I’d love to talk about both how you support cancer patients, but also about diagnosis. So, first, let’s talk about some of the controversy around PSA or prostate specific antigen. Is that the gold standard for testing?

Dr. Geo Espinosa: Sure. So, I have a podcast and I’ve written things on this extensively, if people want to go into a deeper dive, on drgeo.com, everything related. So, thank you. I’m going to say this in bullet point form. PSA is a good biomarker for prostate health, for the prostate itself. PSA is a decent biomarker for prostate cancer as well. So, decent, what does that mean? I mean, is it good or not? Well, it’s decent. If somebody comes in with a PSA of 50, 100, they have prostate cancer, I know that. There’s some value there. I mean, I don’t even need a biopsy. The trick is when the PSA is a little bit elevated because the range that they give you in the labs really don’t matter. That zero to four range that they give you in labs, that doesn’t matter.

Somebody can have a PSA of two and they have prostate cancer. Somebody can have a PSA of 20, and what they have is a big prostate. They don’t have prostate cancer. I see many of those men, but it’s decent. Now, only about 10% of men walking around the world have high PSA. Very high PSA. If I look at just my practice, I say, yeah, PSA, it’s always high in men and should always be high. No, that’s my practice. This is what I do. I see a lot of PSA tests, but if I get out of my practice, which is homogenous, only about 10% of men walking around the world have a high PSA to start with. Most men, 90% have a low PSA. Low meaning what? Depends on their age. Remember the range doesn’t matter. But if they’re 40 years old, they should be less than one.

If they’re 50 years old, I don’t know, they should be between one and two. I’m pulling these numbers out of the air a little bit. If they’re 60, 70 years old and they have a PSA of five or six, I’m not thinking necessarily, “Oh, my God. They have prostate cancer.” That’s above the upper range of four. So, it depends. The other thing that PSA helps is also velocity helps. So, what does that mean? If PSA changes, that PSA kinetics change where PSA rises within a year, so you take four PSAs a year, one quarterly, and PSA rises one or two points every single time, then that PSA velocity to me is like, “Ooh, I need to look into this. I don’t like the velocity. That shouldn’t happen.” So PSA has some value. The other thing that has value is called PSA density.

PSA density is when you take the PSA value and you divide it over the PSA volume, which you only can really get from either an ultrasound or an MRI. So, it tells you the size of the prostate. If the PSA density is above 0.15, then that indicates the possibility of prostate cancer, but this is yet another way of using PSA that’s valuable. Okay, so there’s that. That’s the PSA story. It’s good, but only if you use it properly. It’s not like biopsy right away if it’s X number. No, by the way, unless it’s like 50, like I said, or 30. These are very high numbers. I don’t care what age you are, but 0 to 10, 0 to 20 in older men may not be… Because there’s a lot of benign reasons why the body not only makes PSA, but it seeps into the bloodstream.

So, I think that’s the PSA story. The reason why you’re asking the question and the reason why people are confused, Evelyne, is because in the early 2010 or so, the United States Preventative Task Force said no more use of PSA to screen for prostate cancer, period. The reason for that is because too many people were biopsied when they had a high PSA and they didn’t need to or too many treatments for prostate cancer in cases where they had low indolent prostate cancer and they would never die from it. So, overtreatment caused that to happen, but what happened there was is that now more people that came into the office with prostate cancer now that had more aggressive prostate cancer. So, no, there’s PSA value.

Then the United States Preventative Task Force changed their tune, said, “Well, no. Now it’s category C,” which means it’s a decision between the doctor and the patient. That’s where we are with PSA. There are other better tests that are more specific to prostate cancer that uses PSA, but in some algorithm that uses other what’s called kallikreins, right? Kallikreins are a type of protein and there’s nine of them. PSA is kallikrein two. It’s one of them, and then they use three others. So, this one has called a 4Kscore. It’s pretty good. It’s a blood test. There’s another one called IsoPSA, another one. Again, a little bit more sensitive to prostate cancer and specific to prostate cancer than just PSA alone.

But if we’re saying that PSA is a problem, then sometimes I see a guy with a high PSA, now this PSA kallikrein two is using the algorithm, and now the 4Kscore is high. Is that a real number? Then that’s the question. There’s another test. It’s a urine test called Exosome DX test, and that’s a urine test that does not use PSA. I find that test to be useful. It’s easy to do. You don’t have to do a prostate exam or a massage before urinating in a cup. They just pee in a cup, send it away, and that’s useful. The other test is SelectMDx. Once again, urine test. You do in-office. You do need to massage the prostate and then they pee in a cup and they send it away. Also, they don’t use PSA in that scenario, also good. So, that’s the PSA story in a nutshell. No pun intended.

Evelyne: Thank you. So, if a practitioner is maybe not necessarily specializing in men’s health, but they do see in their practice, do you screen everybody over the age of 60 for it or are there other indications that would make you think, “Okay, I need to get them checked for prostate cancer and run some of these tests”?

Dr. Geo Espinosa: I screen everyone. Again, I think this is separate. The AUA guidelines and the organizations that are providing guidelines to practitioners suggest start PSA testing at 50 and stop at 70. So, somewhere between 50 to 70, that’s when you start. I disagree wholeheartedly. I think that men should start getting their PSA test at 40. I see too many men in their 40s, I mean a low percentage but is not zero with aggressive prostate cancer. In fact, what I’m noticing clinically is that when men in their 40s present with prostate cancer, oftentimes, it is more aggressive than the older men. So, I want to start everyone at 40 and I want to start everyone at 40 period.

Definitely, if they have a BRCA2 gene mutation or a very strong family history or African-American or all of the above, start at 40. At minimum, you have a baseline. Okay. So, if the PSA rises two years, at least I have a baseline. I know that at 48, I was zero or was low. So, no harm, no foul starting at 40. Perhaps depending if they do have a genetic predisposition or a family history of prostate cancer, then I’ll test their PSA once a year throughout their 40s. If it’s a little bit elevated, I’ll check it every six months. So, there’s value with PSA once again, because you see the velocity in changes.

Evelyne: Are there some things that we can do to prevent prostate cancer that you use with your patients?

Dr. Geo Espinosa: There’s one story that says, “Look, all you need to have is a prostate and live long enough and you’re going to get prostate cancer of some sort.” Then there’s the other one that say, “Well, we do some of the right things, we lower the risk.” So who’s right? Who’s wrong? Maybe everybody’s right. There could be two rights. The most important thing is even if you develop prostate cancer, it’s not to develop the most aggressive type because most men die with prostate cancer, not from it. So, the way you lower the risk is based on evidence and my experience, again, that’s a long story, but if I can hit the audience with some takeaways, it’s the following.

You try to create a microenvironment that’s hostile to prostate tumors growth and development. It may overlap with other cancers to some degree, but what I know is prostate cancer is the only oncology that I work in. I’m pausing because the dietary approach is so controversial. It is insane. So, what most people read and think, and a lot of the data suggests that a plant-based diet is the way to go. I don’t disagree with that, except that I don’t define a plant-based diet by excluding animal products. That’s not my definition of it. As it relates to red meat… I get emails and things. Well, the evidence shows that meat promotes prostate cancer. Show me the evidence.

The evidence shows, and this is systemic review and meta-analyses show that there is no association with red meat and forget about grass-fed and all that. That’s different because they’re not looking at that. But there is some association with meats that are cooked in high heat. So, there’s something there, some of these heterocyclic amines and some of the processed meats, hot dogs and sausages and things. There is some association there, but not red meat and certainly not red meat when somebody’s eating a healthy diet with red meat. So, my approach, Evelyne, dietarily is the following. I’m not trying to change who you are. You want to be plant-based or vegan plant-based.

Great. Let’s figure out what’s the best way of doing that because God knows I probably have seen way more unhealthy vegans than I’ve seen meat eaters. So, let’s just figure out a way to, A, do this properly to help your prostate cancer scenario, and B, to get enough protein in because you still need muscle and things so that you can live long enough and be healthy. Those are the two things dietarily. Exercise, I really ask them to give me four to six hours a week of moderate to high intensity, even some mild just movement needs. Some just regular movement is walking.

So, full spectrum. But in terms of moderate to high intensity, I do ask him to give me about three hours a week of moderate to high intensity. There’s some evidence to show that that helps men reduce the risk of prostate cancer and less men die from prostate cancer after they’ve been diagnosed. From a nutraceutical perspective, I tend to use quite a bit of curcumin, but Inflammatone is a great product.

Evelyne: I love Inflammatone.

Dr. Geo Espinosa: Okay, yeah. As we know, I have my own formulations, but I still use Inflammatone in more aggressive cases actually. So, I still use it even though these formulations that I’m affiliated with. So, Inflammatone, go-to, great formula. I remember before I did my own thing, in general, I used to do four to five pills twice a day if they can tolerate a lot of curcumin and things. So, sometimes I get DGI distress. Okay, broccoli extract, again, BroccoProtect, I believe is what it’s called. I mean here I am, I mean all the time, some good quality broccoli extract. Based on evidence, the crucifers have all the chemicals, the plant chemicals that seem to have anti-prostate cancer properties.

So, I’ll have them eat a lot of those and let that be the primary vegetable and then take that in supplement form. So, things like green tea extract as well, quercetin is very good. Anything that can stimulate or modulate the immune system. So, things like magnolia bark and Andrographis are fantastic. Essentially anything that does one of three or four things, reduce chronic inflammation, so your NF-kappa B’s and all these things, protect against oxidative stress, helps detoxification. The liver is a very important organ to just detoxify. Again, the Science of Health has many of those as well. Milk thistle and those that helps the phase one, phase two pathways and some things that seem to have some level of anti-cancer properties in some way or another.

An immuno-modulating, I think I said that, magnolia and Andrographis. Yeah. So, that’s what I’m trying to do. I’m trying to help. So, you do this with good diet and so forth. Sometimes you’re trying to also, depending if they’re on ADT, limit some of those side effects from the ADT. In that scenario, I want to help them with cognition, bone health, because without testosterone, the bones, they become more either osteopenia or-

Evelyne: Osteoporotic?

Dr. Geo Espinosa: Osteoporosis. So, other than weight resistant exercise, which again is key in that scenario, things like boron. I don’t do a lot of calcium in my patients because I just think that sometimes they overdo it and it becomes more of a problem. But I do magnesium, boron. Bacopa is an excellent botanical for cognition. Acetylcarnitine again for cognition and even cardiovascular, huperzine A and things like that and Lion’s mane, things like that to help them with cognition while they’re on ADT. Ashwagandha, again, great.

Question is then, oh, well, ashwagandha while on ADT counteract the ADT. Impossible, the ADT is way too strong. I think there’s way more benefit for taking ashwagandha with men on ADT than downside. It helps them with fatigue. I do off-label recommend black cohosh in men on ADT. So, they get less hot flashes and night sweats like women do post-menopause.

Evelyne: It’s an anti-inflammatory, right?

Dr. Geo Espinosa: Anti-inflammatory and good for bone health also. I don’t think it’s gender-specific for any of those benefits actually.

Evelyne: Yeah, thank you for such a thorough answer and so many clinical pearls in that. We haven’t even talked about prostatitis and benign prosthetic hyperplasia, which are a lot more common than prostate cancer. I don’t know if the statistic that I have here is right, but 50% of men do get BPH or benign prosthetic hyperplasia. So, I want to talk about that. Prostatitis is just inflammation of the prostate, right? What’s the difference between that and BPH?

Dr. Geo Espinosa: It’s a little bit different. So, inflammation is literally inflammation. So, it’s inflammatory, scenarios where now the cells, not more cells are growing, but the cells are inflamed from these inflammatory chemicals. So, these one cells, they grow. Hyperplasia is excessive duplication of these cells. So, there’s too much production of these prostate cells. So, a little bit of a nuance there. Here’s what I’ve seen in patients that I’ve seen maybe thousands of biopsies of the prostate, and almost always, even if they don’t have prostate cancer, not always, but almost always, there’s inflammation. That’s the report. It says inflammation, right?

So I think that’s contributing to prostate problems. BPH I think is confused with BPH. A very important part here, Evelyne, is the following. I don’t necessarily care how big the prostate is. So, a normal-sized prostate is about 20 grams. Twenty grams is about the size of a walnut.

Evelyne: That’s it?

Dr. Geo Espinosa: Prostates can grow into the size of a mandarin, a golf ball, a mandarin and orange, and sometimes even a small grapefruit, right? A small grapefruit is 350 grams. That’s a big size. What you’re trying to avoid by treating the prostate is not just lowering the size of the prostate, and this is why I have an issue with 5-alpha reductives inhibitors, the ones that stop the DHT, because you’re lowering the size of the prostate, great. Most of those men still have urinary issues. What you’re trying to avoid is urinary issues that are associated with the prostate. What you’re trying to avoid is the squeezing of the middle that what’s called a transitional zone of the prostate that squeezes the urethra. That’s what you’re trying to avoid.

So, you can have a 30 gram prostate, not big, with urinary issues that are associated with the prostate. You can have a 200 gram prostate, small orange, no urinary issues. So, the goal is not to just shrink the prostate. The goal is to relieve from urinary issues. So, that’s the conversation to have. It confuses what the goal is. The goal is not just to decrease the size. The goal is to open up the transitional zone so that the person can pee better. So, that’s my focus as opposed to, hey, let’s just give them a lot of saw palmetto and maybe it reduces the size of the prostate with a little bit of 5-alpha reductase inhibiting action. Then that’s not the goal.

Evelyne: Thank you for all those distinctions. I want to talk more about, well, excess peeing and especially at nighttime. I know that’s a big problem for people. I don’t work with men a lot, but the few times that I have recommended flower pollen extract, specifically Graminex, the trademarked one, I was able to have people achieve dramatic improvements in a really short period of time, especially with that excessive nighttime peeing in literally days, like two days. I don’t know if that’s common. I know the studies say more like 12 to 24 weeks. But I was curious what your experience is with that ingredient specifically because I think it’s amazing.

Dr. Geo Espinosa: So it is an amazing ingredient that I use quite often. The question is why is this person peeing a lot at night? Are they peeing a lot at night because of the prostate issue that we were talking about earlier? Is it an actual issue? Are they peeing a lot at night because they’re not sleeping? So there’s an association with things like sleep apnea and nocturia, and what they find is that it’s not a urological issue. It’s a sleep issue. So, you got to ask the question, what comes first? Do you feel that you’re in a deep sleep, very deep sleep, and the feeling of having to urinate wakes you up to go pee? Or do you feel like, yeah, you’re not really in a deep sleep, you’re half asleep and you’re saying, “Okay, let me go pee because I have the urge”?

I sleep very well all the time. If I’m not sleeping well for whatever reason, then I’m going to go pee at night. So, what comes first is a very important question. Maybe treat the sleep. Maybe see why they’re not sleeping well. Maybe treat their stress and figure that out. That’s the issue. Also, remember, the reason why we’re saying prostate in a urinary scenario with men is because they have a prostate. So, you blame the organ you have. You wouldn’t tell a woman with nocturia, “Hey, you have a prostate problem.” Men also have bladders, so they have overactive bladder just like women. So, the issue that I find is that oftentimes that when men have LUTs, lower urinary tract symptoms, is the prostate issue the prostate?

It doesn’t have to be the prostate. It could be overactive bladder. In fact, oftentimes, it is overactive bladder. So, that’s what you want to treat. So, back to your questions because I can digress as you can see, but bring it back is nocturia. So, yeah, so Graminex, right? Pollen extract works really well. Quercetin, excellent. You got a lot of bang for your buck with quercetin. This is just supplements, right? Just behavioral things that we could talk about. Again, Inflammatone, I’ll say it. I’ll say it, Inflammatone, even for BPH, because oftentimes, again, it’s not BPH. It’s like inflammation and other things. Magnesium, what are we trying to do? We’re trying to calm the system, the overactive bladder, the overactiveness of the pelvic area.

So, magnesium is an excellent to give at night, three hours before bedtime, whether it’s glycinate or I’m not exactly sure what form works best. I use a bunch actually. I do use glycinate and citrate and malate, and sometimes I use a few at night because I don’t know which one is working. So, since I don’t know for this particular purpose that is, and certainly they have constipation. That’s the other thing, very important. It’s great because sometimes you do get to see in science that, wow, naturopathic medicine always had a right, the digestive system. Wow, treat the colon.

Wow. There is evidence that show that men who have suffered more from constipation and IBS tend to have more urinary problems and prostatitis. So, you got to treat that. If that’s the case, I do give them magnesium oxide and citrate, so that get bowel movements in place and also perhaps some benefit from the magnesium.

Evelyne: Yeah, thank you so much for that answer. You caught me going green pharmacy there, instead of asking what the underlying reason is. It’s easy to do in our profession.

Dr. Geo Espinosa: Correct, correct. You always want to look, even with a guy that comes in with erectile dysfunction. Hey, are there any PDE5 inhibitors? Well, listen, first, if you’re coming to see me, did you read me up online? Because I’m trying to help you with the cause. If not, look the urologist down here, he’ll get… I don’t have a problem with PDE5 inhibitors. I get it. I’m a man and I get it. It’s a Band-Aid. Why are you not getting erections normally? The penis is a barometer to a man’s health. So, let’s look a little bit more deeply. Sure, it is your anniversary tonight or whatever. New girlfriend, no problem. New boyfriend, I don’t care. Great, tonight, but don’t be dependent and let’s figure out the cause. So, you got to look at what’s really happening at a deeper level.

Evelyne: We could do a whole show about erectile dysfunction. We have talked about it on the podcast before, but I do want to go back just to a few more nutraceuticals, because that is one of the things we’d love to talk about on the show, but specifically things like nettle root, cranberry, pomegranate. I have a note here. I think it’s from my herbal medicine notes, that it delays the doubling time of PSA and like zinc and selenium, just how those fit into BPH or prostatitis.

Dr. Geo Espinosa: So I’d say yes to all. So, cranberry extracts are shown to help men in a study, randomized, I believe, to help men lower their LUTs. Pretty significant. So, cranberry extract. So, yes, pomegranate extract, absolutely, there’s a lot of benefit there. The study that showed that lower PSA had broccoli extract, pomegranate, two others. I want to say green tea and curcumin. Those are the four, I want to say. It was a formula that had those four. So, all those things are good for sure. Selenium is a very important mineral for the prostate as well. So, I would say if I had to rank them, which I shouldn’t do, but I’ll do it anyway. Zinc is number one, and perhaps selenium is number two.

Evelyne: Wonderful. Well, Geo, I think we did it. I think we crammed a whole semester into one episode.

Dr. Geo Espinosa: Exactly, exactly.

Evelyne: We may have to do a part two.

Dr. Geo Espinosa: Somehow we did.

Evelyne: Somehow we did it. We do have a few questions that we ask everybody on the show, just rapid fire if you can. What is something that you’ve changed your mind about in all your years of practice? Maybe the most significant thing?

Dr. Geo Espinosa: That in the field of urology, which is what I know most, medicine works really well when needed. Urologists do amazing jobs when someone needs a medical intervention because your naturopath function, everything. Medicine is bad, medicine is bad, medicine is bad. I took time to know when is it bad? Yeah, that’s why I think natural approaches work very well and urological functions for sure. But when is it good?

Evelyne: Absolutely. Yeah.

Dr. Geo Espinosa: I don’t care about my bias or anything. My patients don’t care about my bias. No. When do I need an intervention that actually will help my quality of life or save my life? There are those situations in medicine. If there’s one takeaway for the audience is don’t be close-minded. I know the problems in medicine. You do too. When is it good? Change the mindset. When is it good? When is it good by itself? When is it good integratively as well? That’s the question to ask. We all know the issues, but when is it good and helpful?

Evelyne: Absolutely. Thank you. What are your three favorite supplements for yourself? Not brands, but the three top things that you take.

Dr. Geo Espinosa: So, I would say curcumin. I believe that lowering my inflammation as I get older is important. I would say ashwagandha. I’m just going to stick to botanicals for now, right?

Evelyne: Yeah.

Dr. Geo Espinosa: Ashwagandha, curcumin, I would say maybe cordyceps.

Evelyne: Nice, right?

Dr. Geo Espinosa: Cordyceps is also good for testosterone, by the way.

Evelyne: What are your favorite health practices that you do to keep you healthy and resilient?

Dr. Geo Espinosa: Weight-resistant exercise and sleep. Those are the two things that I believe, and the supplements I take. My diet sometimes can be better. I have kids, so I eat whatever they leave on their plate, regardless of what it is, just to not throw food away. But I would say weight-resistant exercise and a lot of movement, I would say. I don’t play with sleep. Once it’s time to go to sleep, just stay out of my way.

Evelyne: Good. Well, Geo, thank you so much. This has been such an insightful conversation. I learned so much and the clinical pearls that you shared, and again, your contagious enthusiasm for all of these topics. So, thank you.

Dr. Geo Espinosa: It’s completely my pleasure. I love Designs for Health. I really do, been for a while, been for a long time.

Evelyne: Well, thank you for tuning in to Conversations for Health today. Check out the show notes for resources from today’s conversation. Please share this podcast with your colleagues, follow, rate, or leave a review wherever you listen or watch. Thank you for designing a well world with us.

Voiceover: This is Conversations for Health with Evelyne Lambrecht, dedicated to engaging discussions with industry experts, exploring evidence-based, cutting-edge research and practical tips.