Welcome And Meet Dr Fazam

SPEAKER_00 0:07

Welcome back to Healthy Mind Healthy Night. I'm Yusuf, and today I'm joined by Dr. Khashir Fazam, a Canadian emergency physician board certified in both Canada and the United States, with a clinical focus in obesity medicine, men's health, testosterone-related care, and body composition. He's also a power lifter for Team Canada with multiple Guinea's world records, which gives him a rear lens that lends evidence-based medicine with real-world performance. Today, we are cutting through the noise around testosterone replacement therapy. The myths, the misconceptions, and the question many men quietly can but really ask out aloud. With that, I welcome my guest, Dr. Hash Yar for Zan, to the show.

SPEAKER_01 1:07

Thank you for having me. Absolutely.

What Men Mean By Not Myself

SPEAKER_00 1:10

So Dr. Hash, before we go into the clinical side of this, I want to start with something simple. So when a man walks into your clinic and says he just doesn't feel like himself anymore, so what does that conversation usually open up?

SPEAKER_01 1:31

Yeah, that's a great question because um we actually see that exact same patient that using those exact same words on a daily basis multiple times a day. And so usually the conversation first starts with me checking and seeing like what's going on, how long have they been feeling like this for, what their specific concerns are. Like, are they feeling tired or something different about like their lifestyle? Is something changed with their medical history? So we try to pinpoint the exact cause. And that's uh really the initial point is you want to figure out what changed suddenly. Did this start last week? Did this start a year ago, six months ago? Um, and we want to find out why this happened. So when and why is very important because then we take the next steps into doing some diagnostic testing and really figuring out the why before we act on it.

Debunking TRT Heart And Prostate Fears

SPEAKER_00 2:42

Yes. From your secret position, what's the single biggest myth you keep hearing?

SPEAKER_01 2:51

Oh, yeah, that's an amazing question. So there's uh like I would say amongst the this is a probably very prevalent amongst the entire medical community internationally. So um multiple, I would say the the entire risk profile, all the possible adverse effects, um, there's huge misconceptions around that. And so I would say the fact that they caught directly cause heart attacks, they cause prostate cancer. Um, these are probably some of the biggest misconceptions that we see. And we have very good studies now, the traverse trial a couple of years ago, for example, and newer data showing that testosterone replacement therapy, when done appropriately under medical supervision, for the uh then it does not directly cause prostate cancer, it does not cause heart attacks. We know that patients who have very low testosterone can have poor health outcomes. Um, and I think the medical community also at times there's too much of an overlap between people who use it for performance enhancement reasons, which is completely different, and people who use it appropriately within the medical realm and medical parameters. And so I think the entire world of um the soft and replacement therapy at an international level, we see a lot of misconceptions about um some of the risks. Now, there are risks, of course, like with anything, there are some risks, but um some of the specific things that come up um repeatedly often are from you know several decades ago, poor quality evidence, things that have just been repeated over the years. But we know now from new studies that some of the traditional things that people thought the software replacement therapy can do, it does not do cause those things.

SPEAKER_00 4:34

And where do you think these myths come from? Like is it social media, locker room talk, outdated medical advice you already mentioned? So are all the three things that I mentioned are enforcing each other?

SPEAKER_01 4:51

Yeah, yep. Um, so uh yeah, the locker room one you mentioned is very interesting, it's very accurate. Um, so for a lot of the conventional things that some people learn about the topic of testosterone comes from the the bodybuilding community, especially from um, I would say more specifically in the 1990s into 2000s. 2000s, especially when uh you know, obviously the 90s to 2000s, the internet, the internet came, right? So um then we got an explosion of information everywhere, easy accessibility. So a lot of the bodybuilder people in the bodybuilding community, a lot of their personal experiences with using anabolic steroids and performance enhancements agents and dosing, their personal experiences, so specifically their personal side effects, I should say, became very well known online. And a lot of the you know, current practices and current knowledge base, some of it gets downloaded from those individuals. So we get too much of an overlap between medical, medically prescribed testosterone replacement therapy and performance enhancements. And, you know, it's just a two different world, essentially, right? I mean, yes, it's same, same, same drug, same medication, but it's just two entirely different worlds in terms of what they can do to the body. And certainly there's outdated uh um literature, outdated evidence too from several decades ago that's been repeatedly you know refuted and disproven, um, but it still lingers in the background, unfortunately. So I think it's important we use the best quality evidence that we have, the latest evidence that we have to sort of guide what we're doing.

SPEAKER_00 6:30

Okay, and I think that is important to name because once a myth gets repeated enough, men start making decisions about their bodies based on the rumor instead of evidence.

SPEAKER_01 6:45

Exactly, exactly. And uh we get um some person, you know, in the gym might say something and then they go on social media, and then that particular myth can now fall out everywhere, right? So um, same thing with uh sometimes we see uh a study that one one study, let's say, gets done uh without good quality or has some flaws, but it shows an outcome that is not ideal. Now that study then gets repeated by everybody in the medical community. So I think we need to have good quality evidence to guide what we're doing. And with testosterone replacement therapy, like we know that it's um uh when it's done appropriately for the right patient, correct diagnosis, correct treatment. We know that overall it is relatively safe. You know, there can be some side effects, it can lead to elevated blood pressure in some cases. It can, you know, um, there might be some marginal, very marginal um blood clot risks, but mostly if the protocol and follow-up is not correctly implemented. And then there's things like hair, hair loss, acne, things like that. It varies case by case, uh, fertility and whatnot. But a lot of these are very case-by-case spaces and they vary from individual to individual. And having a correct protocol for the treatment um is the difference between someone who experiences very little side effects and someone who experiences a lot of side effects.

Who Should Test And Why

SPEAKER_00 8:06

Okay. So, Dr. Cash, who should genuinely be considering getting their testosterone checked? Because the popular answer right now seems to be everyone. Yeah. And I'm guessing the clinic answer is more nuanced than that.

SPEAKER_01 8:23

Yeah, so I would say um there's uh two, I would say two answers for this. Um, the first answer, I would say there's uh um anybody who has some of the symptoms of low testosterone, which can be, you know, a sudden change in mood, but without depression, uh poor sleep, um loss of muscle, increase in visceral fat, uh decrease in libido, decrease in drive, a combination of these symptoms that come on somewhat suddenly can indicate that somebody has uh potentially has uh I say potentially, very important term there, potentially low testosterone. Um, and that would be a reason to check. There's a second answer though. Um, and uh this one is a little more theoretical. And uh the FDA recently had a hearing a few couple months back, and their guidance was um that this this is an expert panel, and there was a lot of academic physicians on there, academic urologists, endocrinologists. So it wasn't like they were they're not working for the FDA, these are just academic physicians around the United States, all with you know years and decades of experience and research in this topic. And there was a pretty strong consensus uh amongst this panel that um perhaps uh men should should potentially obtain a baseline level of testosterone at some point. Um, there isn't a specific age recommendation because we don't have the evidence for it, but perhaps when they're you know, before their middle age, maybe somewhere in their 30s or age 40 or something like that. And the reason that might be a good idea, uh, and it's not a recommendation. This is not something with good evidence uh um for it yet, but uh perhaps obtaining uh um, you know, uh having a baseline level at a certain age, let's I'm just gonna say 40 because again, hypothetical. Then when the patient comes back when they're 50, now they have these symptoms. So we have a level to compare to and say, this is where you were before, this is where you are now, and we know that you had a big drop. Or you have not had a drop, you're the exact same, or it hasn't changed much. And so that's a theoretical uh recommendation. I think that needs evidence to be an official medical recommendation, but it's very interesting to potentially have a baseline level to compare to.

SPEAKER_00 10:38

But I think the general answer still is somebody who has uh has symptoms, and you know that is a crucial distinction because not every tired low energy day is a hormonal issue. Sometimes it is sleep, stress, or burnout wearing the costume of something else.

SPEAKER_01 11:01

Exactly, exactly. Yeah, and uh many cases patients uh feel tired, they have some mood changes and lack of motivation, and it turns out, yeah, they're they're not sleeping well. Um they have or they have sleep apnea, or you know, they have uh something else going on, or they're not eating well, they're under a lot of stress, and uh, and you know, stress and you know, stress can also lower your testosterone a little bit too, right? But at the same time, the main cause in that patient's case would be the stress. And so, yeah, there's a lot, lots and lots of non-hormonal related reasons as to why somebody might feel the way they do, which you know, maybe they don't feel as good as they did last year, and there's can often be many lifestyle-related reasons to explain that. It's a very good point.

SPEAKER_00 11:47

Yeah,

What Responsible TRT Monitoring Looks Like

SPEAKER_00 11:50

and let's say once a man does get tested and the numbers come back low. So, what does responsible TRT management actually look like? Because there's a wide gap between proper clinical care and and what some men are doing on their own through online clinics or unregulated sources.

SPEAKER_01 12:12

Yeah, exactly. And I think uh, you know, in our practice, we'll get uh we'll get the once we have confirmation somebody has low levels, they have symptoms, we decide we want to do treatments. We've done their secondary tests and ruled out other causes of low testosterone. Once we start the uh the treatment process, so usually I present options to patients and you know, um, there's uh different modalities, there's injections, there's topical agents, there's pills. Um, there's been other things too over time, like pellets and uh nasal gel in Canada right now, uh, where I am we don't have the um greatest accessibility to those things, but that's okay. Um, but generally once we pick a modality that works for the patient, I mean, some people are very comfortable with injections, some are not at all. Um, some people want cream, they live alone, nobody else is going to touch it. So some people want pills. But regardless, we pick a method that works for the patient. And generally what we do is we start them at a reasonable dose, um, which is obviously a what I would describe as a medical like TRT range dose, where the goal is to raise their testosterone levels, obviously, and raise them into a healthy physiologic range. Um and we implement the protocol, we check their levels after a couple of months and to make sure their levels are in an appropriate range. We check to see if they're if they feel better, if they have any symptoms. Um, we monitor things like blood pressure and then we do other blood tests, um, for example, to make sure they're not getting their blood's not getting too thick, their cholesterol is okay, and so on. If there are any minor issues, then we tend to make some tweaks and some changes and adjustments to account for those things. And having close follow-up after a couple of months is very important to make sure we've uh we're catching on to those things. So rather than giving a prescription and saying, you know, good luck, we'll see you and see you next year, kind of thing. In contrast, like you mentioned to people who just uh do it themselves, um, yeah, the issues you run into is, you know, maybe the blood your blood's getting too thick, your blood pressure is going too high, maybe the your cholesterol is going in the wrong direction. I mean, these are all things that can happen very quickly when someone is not being monitored. And that's why having like that, you know, we can call it medical supervision and call it, you know, medical appropriate TRT, but having that proper plan in place. Um in my practice, you know, we have very, very few patients who run into any major, honestly, into any issues at all. I would say, you know, 99% of the time, uh, the very tiny little tweaks, uh things we catch, we can make a tweak and make adjustments and prevent it from getting worse.

SPEAKER_00 14:54

And you know, that is important for listeners to hear clearly because the cost of getting this wrong isn't just wasted money. It is your body, it is your biology that does not always forgive shortcuts.

SPEAKER_01 15:12

Yeah, exactly. Um, because yeah, it you know, that like testosterone, they can get it. It's not too too expensive compared to come some other things out there. But um ultimately, if you miscalculate and you do it incorrectly, I mean, yeah, you can certainly end up with if you're taking too high of a dose, lack of monitoring, you can end up with a blood clot unexpectedly, you know, you can have high blood pressure that's damaging your kidneys, for example. All these things can happen. Um, which had things been done correctly, it would have been caught very soon by by the by the physician. And I think that's why having that, you know, in-person assessment, having close follow-up is very important for these patients.

SPEAKER_00 15:57

You sit at this rear intersection of emergency medicine, obesity medicine, and elite performance.

Prevention Mindset And Earning Trust

SPEAKER_00 16:05

I want to know what is something you have come to believe about men's health that the wider conversation has not quite caught up to yet.

SPEAKER_01 16:18

Yeah, I think uh because in my in our practice, we do weight loss medicine, of course, as well. And so, you know, in the emergency side of things, in the emergency room, I see patients with acute issues. And some of these cases have um, you know, acute illness that from something that could have been prevented. And so when I do my weight loss, metabolic health, men's health medicine side of things, I'm essentially working to prevent patients from having to need an emergency room, essentially, right? And um, through my experience in power lifting, you know, um, you know, I compete uh, you know, drug tested, our federation's wada drug tested, and so um, everybody is uh substance free. And so, but uh regardless, through the years of doing the sport, you're gonna have interactions and so on with people who use uh performance enhancing agents. And so that's where you sort of learn and you sort of triangulate these things. And uh what I see is that a lot of these uh patients who end up in the ER from very or various reasons, they end up having things that are preventable. Um, that and that's what I tr strive to do in on the clinic side of things in my clinic is to prevent patients from developing any acute illness.

SPEAKER_00 17:43

How do you talk about this with men who are you skeptical of medicine or feel their concerns haven't been taken seriously by other doctors?

SPEAKER_01 17:55

Yeah, it's definitely something we run into quite often. I mean, some people uh um say, well, you know, I've been to other places and I've asked to get checked and I have these symptoms, and you know, they didn't want to check. And so that does happen. Um, I know different physicians and so on sort of practice within their comfort levels and training. And something I've strive to do, you know, I provide e-consults to physicians, and so I strive to provide education. And I think obviously there's room to learn more, but I think for a lot of these patients, uh, I usually we have sit down, we have a chat, we see what their exact concerns are. I try to find like pinpoint a cause as to why they feel the way they do. Um, yeah, many of them uh feel like, you know, and some of them not necessarily with individual individuals in the past, but they feel like the system hasn't been as helpful for them. But I think it's really just a matter of hearing their concerns, seeing what they think, making sure they feel heard, and then we just

Where To Learn More And Safety Notes

SPEAKER_01 18:55

go from there.

SPEAKER_00 18:57

Yeah. Dr. Cash, for people who might want to connect with you or want to learn more about your work, where can they do that?

SPEAKER_01 19:07

Yeah, so um, if they go on uh true northmetabolic.com for anyone in Canada, we're in Kitcher, Ontario, and so we do um uh uh in-person consultations, and then uh we do can we have the option of doing uh virtual follow-ups for patients who've uh been to our clinic, and we serve patients from all around uh Ontario. We have many patients from many, many hours away that come and see us. So the true northmetabolic.com.

SPEAKER_00 19:38

Perfect, and to everyone listening, all these links are in the show notes, so just go and check those out. Is there any last message that you want to leave us with?

SPEAKER_01 19:50

Yeah, I just think that if uh for anybody, if you have symptoms, you know, don't be afraid to have a visit with your physician and inquire about it and uh see what uh they think would be the next best step for you. Just uh don't be afraid to go in.

SPEAKER_00 20:06

Thank you so much, Dr. Cash, for coming and blessing us with your presence and your knowledge and your unique take on the medical advice and TRT. Thank you so much, sir.

SPEAKER_01 20:20

Thank you.

SPEAKER_00 20:22

And to everyone listening. Quick and important note before we close. Because tonight's conversation was educational, not a medical advice. So if anything you heard resonates, take it to a qualified physician who knows your full picture. Don't diagnose yourself online. And please don't medicate yourself based on a podcast. Use this episode as the nudge to ask the question, not as the answer itself. This has been Healthy Mind Healthy Life. I'm Yusuf, take care of your mind, take care of your body, and I'll see you in the next conversation.