Frequent questions that we’ve had over the years.



It’s very common to have all sorts of questions when it comes to what we do, or even for new patients as they get started with their care under our practice. There is a lot of misinformation on the internet; and, there is a lot of misunderstanding by consumers and even healthcare providers, in some cases. We want to share our knowledge and expertise, supported by the science, to help answer any questions so that you don’t have to waste your time searching all ends of the internet. 



I was diagnosed with Low T, is taking testosterone safe?

Testosterone replacement therapy (TRT) has gained popularity over the last decade given the significant benefits that men, with low testosterone, report after starting testosterone therapy, particularly the sexual effects, effect on mood, improving exercise capacity, and staving off frailty. 

There are nearly thirty years worth of scientific data that demonstrate having normal endogenous (made inside the body) testosterone levels, or the use of testosterone replacement, provides protective benefits against negative cardiovascular outcomes. This wasn’t challenged until two studies were published rapidly in succession in the end of 2013 and the beginning of 2014. These data brought up a considerable amount of undue concern and even resulted in the FDA labeling testosterone with a warning of heart attack risk. 

These studies have been disputed by many scientific advocacy groups based purely on the quality of the studies. The linked blog post provides an example of how the “funny math,” as it’s been called, is applied to the numbers of the 2013 study that was published in the Journal of the American Medical Association. There is also a video attached of one of the world’s leading testosterone researchers, a Harvard trained urologist, Abraham Morgentaler, MD.

I was prescribed testosterone, when will I see a difference?

  • Insulin sensitivity may improve within few days, but effects on glycemic control become evident only after 3-12 months.
  • Effects on sexual interest appear after 3 weeks plateauing at 6 week. Changes in erections/ejaculations may require up to 6 months
  • Effects on quality of life manifest within 3-4 weeks, but maximum benefits take longer.
  • Effects on depressive mood become detectable after 3-6 weeks with a maximum after 18-30 weeks.
  • Effects on erythropoiesis (increase in red blood cell production) are evident at 3 months, peaking at 9-12 months.
  • Prostate-specific antigen and volume rise, marginally, plateauing at 12 months; further increase should be related to aging rather than therapy.
  • Effects on lipids appear after 4 weeks, maximal after 6-12 months. 
  • Changes in fat mass, lean body mass, and muscle strength occur within 12-16 weeks, stabilize at 6-12 months, but can marginally continue over years.
  • Effects on inflammation occur within 3-12 weeks.
  • Effects on bone are detectable already after 6 months while continuing at least for 3 years.
I feel too young to have erectile dysfunction, can you help?

Yes. Erectile dysfucntion (ED) can be an embarassing problem to bring up. It’s ok if it takes you until the end of the appointment to even ask, if your provider doesn’t bring it up first. There are a number of prescribed medications that are effective for treated ED in men. But if a man developds ED, he should also be screened for cardiovascular disease becuase ED is a red flag that there is possibly a blood flow problem.



Do hormones increase a woman's risk for cancer or a heart attack?

There is a fair amount of misunderstanding amongst both healthcare consumers and healthcare providers regarding the safety of hormone replacement therapy, particularly in the case of treating women in menopause. Much of this misunderstanding comes from a research study performed near the turn of the millennium call the Women’s Health Initiative (WHI).

In the WHI, they used non-isomolecular, also referred to as ‘synthetic,’ hormones. The first drug is called combined equine estrogens and is primarily hormones derived from pregnant horse urine. The other drug was called medroxyprogesterone acetate; which, sounds like progesterone, but doesn’t quite act like it in the body. Data from the study showed that there was an increased risk in breast cancer, vascular dementia, blood clots, heart attacks, and strokes.

There has been substantial subsequent scientific research that shows both safety and efficacy from isomolecular (identical to what the body makes), also referred to as ‘bioidentical,’ hormones (e.g., oral estradiol and micronized progesterone). The image above also links to a blog with a deeper dive in to the topic and the references for the safety and efficacy of bioidentical hormone replacement therapy (BHRT). 

What can I expect during menopause


For some women, it’s just a couple months of hot flashes and night sweats. Insomnia can plaque women going through the transistion and the lack of sleep can feed in to the mood swings and irritability and some women will get depressed. Many women can gain weight, and the libido can decrease. 

Once some of the waxing and waning symptoms have subsided like hot flashes and night sweats, have subsided, a woman may complain of brain fog and memory issues; vision problems and dry eyes; loss of elasticity in the skin; loss of vaginal elasticity, vaginal dryness, vaginal itching, pain with sex, pain without sex, urinary tract infections, frequent urination, painful urination, incontinence. Bone density can start to decrease, cardiovascular disease can accelerate, and the risk for Alzheimer’s disease can increase.

But these issues can all be treated with bioidentical hormone replacement therapy.

How often should I see a women's healthcare provider?

Periodic visits for reproductive and well-woman care are recommended, even if individual components of that visit (e.g., cervical cancer screening or mammogram) may not be indicated each year. The periodic well-woman care visit should include screening, evaluation and counseling, and immunizations based on age and risk factors. The timeframe for care is dictated by that provider based on guidelines for your age and the provider’s clinical judgement. 



What is a CIMT test and why should I get one?

The carotid intima-media thickness (CIMT) test is an ultrasound examination of the main arteries (carotids) in both sides of the neck. The test measures the thickness of the lining of your blood vessls with an accuracy up to 0.005 mm, which is 10x smaller than a strand of most hair. The test also assesses for the presence, and characteristic of atherosclerosis, or plaque, in the artery wall. This test has been shown to predict who will have a heart attack with up to 98.6% accurracy. Click the image above to get in to more detail on the topic.

I've heard lipoprotein(a) is bad, should I check if I have this?

The short answer, Yes.There is some good scientific data that has established a strong link between Lp(a) and a number of different adverse cardiovascular problems, maily heart attack (4x increased risk); aortic stenosis (3x increased risk); and coronary atherosclerosis (narrowing of the arteries in the heart) (5x increased risk). Click the image above for a deeper dive.

What is the difference between 'good' and 'bad' cholesterol?

Apolipoprotein B

Cholesterol can’t be good or bad. Cholesterol is just cholesterol; it just gets carried around in different lipoproteins, which act differently in the body, largely in part because of their surface apoproteins. Click the image above to read the full blog if this is something that interests you. 

What's the proper way to check my blood pressure?

The most important thing about checking blood pressure is ‘setting the mood.’ By that, I mean the environment, your body position, and how relaxed you are. Becuase if you are stressing about your email while your child is tugging at your leg, or even if you need to use the restroom, your blood pressure will be in the high range. It’s normal to have fluctuations in our blood pressure from moment to moment. 

Blood pressure should be take three times in a row, with 1 minute between each reading, then calculate the average of the three readings. Some of the automated cuffs do this automatically and pair via bluetooth to transfer the data to your phone. I like the brand Omron.

How to set the mood:

  • Leave your phone in another room.
  • Be alone.
  • Sit in a chair or lay on a flat surface for a minimum of 5 mines. 
  • Keep your legs uncrossed.
  • The arm cuffs are applied to the upper arm and are in the right position.
  • If you are using a wrist-cuff, it must be rested at the level of the heart.
  • If you are seated with a wrist cuff, support your wrist in front of your chest.
  • If you are laying flat with a wrist cuff, lay your wrist on a pillow so that the cuff is on the same plane as the center of your body.
  • Take 3 readings, each one minute apart.
  • Calculate the average of each number.
  • Record all this data to share with your healthcare provider.




What's more dangerous, inflammation or cholesterol?


Inflammation. More than 20 years ago, scientists discovered that inflammation was associated with an increased risk of having a heart attack or a stroke. But for years, there wasn’t clear evidence that anti-inflammatory treatments could reduce the risk for a heart attack or stroke, until about 2008. There was a research study called the JUPITER Trial, which showed that reducing inflammation, even if cholesterol was normal, was very important in reducing the incidence of adverse events.

In 2017, a landmark research study, CANTOS, was published that showed that targeting inflammation, without changing cholesterol levels, can have a significant impact in reducing adverse cardiovascular events. This trial looked at the use of an injectable, anti-inflammatory, drug for people who had suffered a previous heart attack and still had persistent elevations in inflammation, despite the use of other medications.

Cholesterol is a risk factor for cardiovascular disease and atherogenesis (plaque development in the arteries), but there are more significant risk factors like elevated inflammatory biomarkers and insulin resistance. Click the image to learn more. 

What are the risk factors for a heart attack?

I call this group of issues the CVD Dirty Dozen℠. Click the image to take a deeper dive in the the details of each of these issues. 


  • Family or Genetic History
  • Negative Metabolic biomarkers
  • Inflammation biomarkers
  • Periodontal Disease
  • Sleep Disorders
  • Erectile Dysfunction
  • Negative Lifestyle Habits
  • Fatigue
  • Migraine Headaches
  • Autoimmune Disease
  • Toxic Burden
  • Hormone deficiency
What is metabolic syndrome?

Metabolic syndrome is important to have diagnosed because it is a significant risk factor for cardiovascular disease and type 2 diabetes. The categories include blood pressure (BP), waist circumference (which can have some ethnic differences); triglyceride (TG) concentration, HDL-cholesterol (HDL-C) concentration, and blood sugar concentration. Each of the categories has a cut point, that once reached, gives you a strike for that category. You only need 3 strikes to make the diagnosis. Click the image to get in to the details of the numbers.

How do heart attacks happen?

While plaque buildup inside the wall of an artery is certainly part of the problem, it’s interesting to note that 68% of heart attacks occur in a blood vessel that’s less than 50% blocked and 86% of heart attacks occur in a blood vessel that’s less than 70% blocked. An even scarier statistic is that you can pass a treadmill stress test with a 70% occlusion in the main artery to your heart then leave the testing site to have a heart attack in the parking lot; it’s happened.

When plaque is present in the artery wall, and large enough (less than 50%), inflammation in the plaque, the wall of the artery, and in the blood can lead to the plaque rupturing. If this occurs, the body will see this rupture as an ‘injury’ and attempt to stop the bleeing by forming a blood clot (like a scab) at the site of rupture. This blood clot, called a thrombus, blocks the flow of blood downstreatm. Then the heart tissue will be starved of oxygenated blood and begin to die.



Are there any foods that can help me lose weight?

There are no foods in particular that you can consume to make you lose weight but there are certainly things to avoid if you want to lose weight. We have developed a metabolic health protocol that has helped a number of people reverse insulin resistance and even type 2 diabetes, but it also has the effect to reduce body fat, reduce blood pressure, improve fatigue, improve cholesterol and triglyceride levels. Some important aspects of the protocol are: 


  • No fructose in the diet (except 1-2 servings of fruits with high vitamin C)
  • No refined carbohydrate
  • Time-restricted eating
  • A prescribed type, and particular amount, of different exercise
What is your opinion on a keto, or high-fat diet.

Fat is terribly understood, mostly becuase of internet hype and bad press. When I give guidance on a high-fat diet, I prefer the sources of fat to be plant-based (except coconut or MCT oil) and be composed mainly of monounsaturated fat (e.g., avocado, macadamia nuts, and extra virgin olive oil). Other sources of healthier fats are oily fish (e.g., wild caught salmon, sardines, and even trout),seeds, and some other nuts (except the peanut [which isn’t actually a nut] and the cashew).

Based on genetics, and metabolic health, the body can handle dietary fat differently. An easy way to understand this is that the body can clear blood cholesterol out more slowly in certain individuals. They type of fat consumed makes the biggest difference. High amounts of dietary saturated fat can cause a significant increase in calorie intake, production of blood cholesterol levels, and even an abundance of triglyceride, and fat deposition in the organs.


What is your opinion on carbohydrate?

There is just as much confusion with carbohydrates as there is with fats. Carbs aren’t all bad but they most certainly aren’t all the same. Many individuals argue that refined, high-glycemic, carbohydrate is the root cause of most of the chronic diseases is civilized societies. Easy rules to stick to are:


  • Avoid carbohydrate products derived from refined grains (e.g., white bread, packaged bread products, pastas, white rice, etc)

  • Avoid carbs (except from green veggies) with dinner (e.g., have a protein and a green veggie)

  • Avoid sucrose and fructose (particularly high-fructose corn syrup) found in soda, sports drinks, fruit juice, packaged foods (fructose in vitamin C containing fruit is ok) 
  • No agave nectar, maple syrup, or honey

  • No dried fruit

  • Avoid alcohol (particularly beer and mixers)
What are red flags for sleep disorders?

If any these risk factors apply, it would be worthwhile having a conversation with your healthcare provider about screening your for a sleep disorder.


  • Are conscious of waking multiple times per night
  • Snoring loudly at night
  • Been, observed by a bed-partner, to stop breathing while you sleep
  • Wake in the middle of the night gasping for air or heavily sweating
  • Choking or snorting while sleeping or laying on your back
  • Regularly wake with headaches or feeling unrefreshed
  • Feel tired, fatigued, or sleepy during the daytime
  • Often require either daytime naps, or caffeine, to make it through the day
  • Fall asleel on the couch after dinner
  • Have ever dozed off in a meeting at work, or as a passenger in a car
  • Have ever been, or are currently being treated for high blood pressure (or you know its elevated [>120/80] and it’s not being treated)
  • Are overweight
  • Have a large neck circumference (>16″)
Is there anything I can do to improve my sleep?

Sleep can be a tricky problem but someone who is experienced in treating sleep issues can usually get to the root of the problem. The first step would be to get seen by your healthcare provider and be screened for any obvious sleep disorders (e.g., insomnia, sleep apnea). We have developed an entire sleep protocol but the most important things that anyone can start doing today are:


  • Set a consistent routine – wake up at the same time every day, including weekends, let your waketime dictate your bedtime so that you get at least 8 hours of sleep opportunity.
  • Set the temperature in your room to about 66 degrees farenheight. The body requires a couple degrees drop in temperature to both induce and maintain sleep.
  • No caffeine intake (e.g., coffee, energy drinks, pre-workout mix) 14 hours prior to sleep.