The Power of Peptides: Personalized Men’s Health Optimization

Tracy Gapin, MD, FACS

Oh, thanks Matt. Glad to be here with you.

Matthew Cook, M.D.

So give me… It turns out I spent the first half of my career doing anesthesiology. And my real good friend, Shahram Gholami is a urologist and so, had a surgery center where we did urology and orthopedic surgery. And so we did mostly orthopedic surgery, and I did ultrasound guided nerve blocks to put parts to the body to sleep for surgery. And then the rest of the time, I hung out with a bunch of urologists. So I spent most of my life with urologists. And so the fact that you’re coming in warms my heart. Tell me about your journey of how did you get started in integrative health and how did that happen?

Tracy Gapin, MD, FACS

Yeah, I think that’s a great question. So I have been practicing urology for 20-plus years now in a high volume busy practice here in Sarasota, Florida. Started out doing a lot of robotics, doing a lot of big open surgeries in the hospital. And after a while, you start to get disillusioned with healthcare. You get really disillusioned, disenfranchised with are we actually making a difference? These guys will come into the office 250, 300 pounds, just wanting their Viagra pill for sex. And I found that guys were not really necessarily experiencing the transformation that I was hoping to really provide. I went through my own health issues about now, seven, eight years ago or so, where I actually went to see a doctor for the first time in my life. And it’s very interesting and a very vulnerable experience to be on the other side. 

And that really opened my eyes to, without belaboring the story, I’ll just say that it opened my eyes to how we, as medical doctors, have no idea how to really promote or optimize health. We are taught how to treat disease, how to stamp out symptoms, let me offer this operation, or this procedure, or this prescription medication. And that’s really about it. That’s what we’re taught. We’re taught pharmaceuticals for this problem. And so it hit me when my health was deteriorating, and I was not able to be the husband and father that I needed to be, that shit, I got to change my own health. I got to upgrade, and I don’t even know what the hell to do for myself, let alone for all these guys who are coming to my office. And we’re taught in our medical training very little about health, nutrition, fitness, sleep, let alone hormones. We didn’t have one day of actual hormone optimization training in urology in residency.

Matthew Cook, M.D.

Isn’t that crazy?

Tracy Gapin, MD, FACS

And so I realized that I had this need and this desire to learn more. And that got me into the field of functional medicine and epigenetics. I went through a epigenetic certification program to read your genetics and understand how to implement that to your life. Went through peptide certification program to learn about the amazing benefits of peptides and how we can really take a precision-based personalized approach to health. Learn about home optimization from some of the experts around the world. That was an entirely new arena that you would think a urologist is the expert at, but we have no idea. Urologists had no idea how to manage hormones. And so I took all these experiences, all this training, all these certifications, and put them together, and created this focus, this passion that I have. And Matt, I was done with medicine. It was about six, seven, eight years ago, I was just done with medicine. I hit a wall where I just, I wasn’t really enjoying it. I didn’t feel the benefit, I wasn’t really feeling like I was providing the transformation that men needed. Now, I love coming to work every day, Matt, I love the change I’m making in men’s lives. And it’s a whole new world.

Matthew Cook, M.D.

I had a similar thing where I started to get a little bit of brain fog because I was breathing anesthesia gasses all day. Same thing. And so then, and as I sat there, it’s interesting because we both, I started to realize I needed to hit the eject button from Western medicine. And now, what I do is totally Western medicine, but it’s integrative with all of these other things. But I remember vividly seeing all of these men and women who were 10 years older than me that were totally falling apart. And especially in anesthesia, you really see people like they… 30-year-old anesthesiologists look like they’re the healthiest people on the planet. And they really do. And the people in their 60s looks like they’re dying. Barb told me, she goes, “Back when I first met you, you could smell the sevoflurane on you.” And she goes, “You still had it for a year after you quit doing anesthesia.” So I echo those thoughts, but you hit the eject button at just the right time. And I would say, when it comes to functional medicine, I think one of the areas that I think has been from the very beginning is hormone optimization because that becomes something that, if you start to balance those hormones, it starts to balance biological systems. And so it becomes an input that helps get people better. Could you walk me through how you think about that? And I know that you can give people creams, you can do injectables, you can do pellets. How do you think about the risks and benefits of some of those different things? And how do you guide somebody through a journey of that?

Tracy Gapin, MD, FACS

Sure, I think it’s important first, Matt, to, if I can take a moment to take a 30,000-foot view of the, of my entire approach ’cause I think this would be valuable for the listeners as well. Yeah, so I’ve developed what I call the MALE framework. MALE is my fun acronym dealing with men’s health of how I take a systems approach to health. And when we think about functional medicine and Western medicine, there is this integration that you and I are both really passionate about where I can combine all these aspects of health to provide the transformation and the outcomes that men need. And so my MALE framework is acronym for M is mindset, A is aging, L is lifestyle, and E is environment. And I’ll just quickly fly through these. Mindset, I’ll talk a lot about stress and stress resilience. And what is your why and overcoming limiting beliefs. Because one of the first things men need to understand is how to overcome these limiting beliefs that they can’t change, and that they’re not able to change, and get past those thoughts. Focusing on living with intention, and what is your why and really staying true to what your goals are and never swaying. 

How to deal with stress. I believe that stress and the cortisol effect that we have from stress is a big culprit when we look at all the underlying health problems like sleep, and hormones, and obesity, and metabolic syndrome are all intimately tied to cortisol. So that’s M. A is aging. This is where I look at all the processes when we think of the aging process, and this is where hormones come in. And so you were mentioning testosterone before. And I like to say that a lot of docs out there are only focused on testosterone, and come get your T shot pellet or whatever. And I go, quote, beyond testosterone, and I look at thyroid, and DHEA, and cortisol, insulin, melatonin, progesterone, vitamin D, estradiol. All these hormones are like a symphony, and the interplay is magical. And so you have to really address all those hormones or else, you’re really missing the bigger picture. 

Under aging, also look at cellular efficiency, cellular function. And this is where we could talk about peptides, the amazing power of peptides to optimize cellular efficiency. And then reducing chronic inflammation, which we know is a big culprit when we look at aging as well. L is lifestyle, nutrition, sleep, and fitness. I take a very precision genetics-based approach to lifestyle where based on your genetics, you may do better with certain types of diets, or detox programs, or fitness plans, or whatever it may be. And then E is environment. Looking at gut health, immune function, detox, toxic exposures to endocrine disruptors. So that kinda gives you the general ballpark of how I approach all this. And so to dial deep down in any one of those, I like to just be sure that I emphasize that, hey, we got to be sure we’re not missing any of these other aspects of a much bigger systems approach.

Matthew Cook, M.D.

Okay, so then I 100% support that like with my whole being. It goes to show… It is kind of funny, I was talking to Dr. Plant, one of my great younger doctors. And then basically I said, I go, here’s the thing, I go, “I did the same thing. I busted my butt and worked as hard as I could and it got to that point when I got done.” And then I go, “You’re starting a new moment when you have to actually learn to crush a super healthy lifestyle. ” And so then that means you got to learn, you have to become an amazing cook, and you have to, and then hot and cold, and exercise, and then managing all of that. Because I think you talk about age management, if you can really dial all of that stuff in, and that’s exactly, what you just said is exactly what I think everybody should do, 100%. You probably could practice medicine until you’re 80. I can’t see stopping. Like I’m gonna probably do just as much medicine when I’m 75 because we need to change the world for a better place, and there’s gonna be, continue to be things going on. If we don’t do all of those things, and then those things set up by a chemistry to kind of work better, basically.

Tracy Gapin, MD, FACS

Yeah, without question. Yeah, completely agree with you. And when it comes to lifestyle, you see so many patients in my practice, I’m sure in yours as well, who will want the magic bullet. Like can you just gimme testosterone alone? Or tell me just the exact pill supplement I need to take, or gimme the peptide that’s gonna make it so I don’t have to worry about exercise, or I don’t have to sleep, or I don’t have to worry about eating the right foods. And there is none. And I think that’s really important to point out that we’re here on this Peptide Summit to talk about the amazing benefits of peptides. But I really see them as the icing on the cake. And if you haven’t baked a good cake, that icing doesn’t help, it doesn’t do anything. And so I think there’s really important to lay the foundation first.

Matthew Cook, M.D.

So that’s a good one. I, in fact, 100% agree with that, which is why I’m leaning some other aspects of the conversation. And I’m actually gonna lean out. So I like what you said, so I’m gonna come back to where we started, which was hormones. But then like, I just 100% agree, it’s not testosterone, okay? It’s this symphony of all of these things. So you mentioned vitamin D, you mentioned the thyroid hormones. And I think it’s super important. Maybe take me through that, your perspective kind of on hormonal and biological system balancing from 30,000 feet.

Tracy Gapin, MD, FACS

Yeah, sure. So if we’re dialing into the hormone section of that A column, if you will. I do a deep functional assessment looking at hormones. So when we’re looking at testosterone, you wanna look at free and total testosterone, you wanna look at SHBG, you wanna look at DHT or dihydrotestosterone, which is what testosterone can get converted into, you wanna look at estradiol.

Matthew Cook, M.D.

Tell ’em what SHGB is.

Tracy Gapin, MD, FACS

Yeah, so sex hormone-binding globulin. And the way to think about this is your pituitary tells the testicles to make testosterone. Testosterone gets produced and enters the bloodstream. And a lot of it, in fact, most of it will get bound to proteins in the blood. SHBG is the largest component of that. Albumin and some other proteins to a lesser extent. But what happens when these proteins bind to testosterone, it makes that testosterone relatively, in our keyword there relatively, ineffective. So for testosterone to work, it has to enter the cell, go to the nucleus where it binds to the androgen receptor to have its actual effect and causes transcription, translation, protein production, and its ultimate biological effect from that testosterone. If it cannot get into the cell, then you have a problem where the testosterone’s not actually having the effect that you wanted to. And so that’s why we look at free testosterone. 

And I’ll see a lot of guys who will come in, and they’ve only had their total checked, which I would consider fairly worthless because we wanna really look at the free testosterone and that ratio of the two. Now, I’ll briefly step back also, and talk about the reference range for testosterone and for free testosterone. Now, there is, I’ve talked about this on stage about endocrine disruptors and how they’re really crushing our testosterone, and we’re experiencing a testosterone pandemic worldwide. We have seen testosterone levels plummet by over 30% over the last 20 years, over 30% decline in total testosterone, over 40% decline in free testosterone. It’s crazy. Yet that reference range, which is 200 to 800, people consider the normal range. That’s nothing more than the average of the population. You look at the median and you take two standard deviations on either side, and that’s your reference range. 

And so when you look at a lab slip for total testosterone that says 200 to 800, why God, that’s not the normal range. That’s just what we’re seeing because testosterone levels keep plummeting worldwide. And so in reality, you and I know that depending on what lab, what scale you’re looking at, but you want a free testosterone of around 20 to 25 or so, or 200, 250, depending on what scale you’re looking at. That equates to a total testosterone that may be 800. And believe it or not, get ready to cringe here, that may require a total testosterone of 1,500. But if that’s what it takes to get your free up to the healthy, normal, optimal levels, then so be it. But I wanna be clear that range that you see on the lab slip is not the normal, healthy, optimal range. That’s nothing more than the reference range. And that’s where a lot of doctors make mistakes.

Matthew Cook, M.D.

And do you credit endocrine disruptors as the primary cause of that drop in testosterone?

Tracy Gapin, MD, FACS

Yeah, I wholeheartedly do and I plant my flag on that. And if you could find my talk on YouTube where I go through all the studies on this, but there is some fairly fascinating published literature on all the different chemicals in our foods, in our water, the birth control, the atrazine, the phthalates, the BPA that are clearly causing a direct effect on hormone production. And that’s not just testosterone. We’re seeing effect on thyroid, it’s related to obesity, autoimmune disease, even cancer, even increased risk of cancers, yeah.

Matthew Cook, M.D.

So then to restate that, there’s basically a sea of pollutants and toxins that we live 

in that are at higher and higher levels that we’re getting assaulted with all the time. And then those will cause our body to make, they’ll disrupt our endocrine system, which is the system that makes hormones, and then we’ll have, and so now compared to the past, we have lower testosterone levels. And hormone levels of all kinds.

Tracy Gapin, MD, FACS

Yeah, I love that you said a sea of it. I jokingly call it an endocrine disruptor soup.

Matthew Cook, M.D.

Oh.

Tracy Gapin, MD, FACS

That we are bathing it. Exactly right, yeah. And a couple effects. One is it could crush testosterone levels, hormone, testosterone, thyroid levels, or it can bind to the androgen receptor to make the receptor not work, or it can mimic the hormone itself, like turning on a light switch that won’t turn off. So a couple different ways that endocrine disruptors can work.

Matthew Cook, M.D.

Okay, so then I like how this conversation’s going because then what that means is if you rewind back to the beginning, and then this kind of goes to show you kind of probably a shared philosophy that we would have. So then the conversation that was maybe less exciting, which was that detox, lifestyle, wellness thing is suddenly important because all of that soup or that sea that we’re swimming in is actually disrupting and making, either us not make hormones or block where the hormones work so that then basically our biochemistry is somehow stunted, I guess.

Tracy Gapin, MD, FACS

Yeah, I absolutely agree that statement, Matt, exactly. So under the E for environment column, I talk a lot about upregulating your detox function so that your body is better able to clear toxins through phase one, phase, two detox systems in your liver, glutathione, et cetera.

Matthew Cook, M.D.

How do you do that? How do you like to do that?

Tracy Gapin, MD, FACS

So based on your genetics, actually, I can look at superoxide dismutase, and glutathione, and catalase, and really identify some potential weaknesses, and I can potentially provide supplementation. A lot of it’s diet, nutrition, cleaning up what you’re eating as well as peptide are great as well.

Matthew Cook, M.D.

So basically, these are enzyme pathways that do a job of detoxification. And so there are supplement and other strategies to sort of get them going and sort of turn them back on.

Tracy Gapin, MD, FACS

That’s right. They help your body clear the trash, yeah. And then the other part of that is the toxic exposures. Coming back to the full systems approach, if you’re not eliminating those toxic exposures, then you’re wasting your time taking testosterone. If you’re not clearing your drinking water, not using plastic water bottles, but using stainless steel. If you’re not eating organic, if you’re not eliminating the personal care products that we know are loaded with these toxins, you’re wasting your time.

Matthew Cook, M.D.

Now, in 1910, what do you think the, if I had a time machine and I could go back and do some blood tests, what do you think the testosterone would’ve been for a 35-year-old guy?

Tracy Gapin, MD, FACS

Yeah, so we’ve actually seen studies where a 50-year-old guy, and there were three studies. The Male Massachusetts Aging Study was the US one, and there was one from Sweden and Finland as well that looked at this exact question. Now, they did not draw blood from 1910, don’t don’t get me wrong. But this was back from 1950s and ’60s, actually, we’re looking at blood levels. And what they saw was a 50-year-old guy today has a 30% lower testosterone level than he did 20 years ago. And so you can extrapolate that, and I’m sure it doesn’t keep going all the way infinitely, but I know that there’s a steep curve over the last 50 years as more of these toxins have come into our environment that we’re seeing a dramatic change, so. I mean, hell, if I would guess, I would say maybe either total testosterones were 1,000, perhaps. Who knows? It’s guesswork, obviously. But there’s been a clear deterioration of hormone levels. And I personally believe that the biggest culprit, diet, stress, et cetera, are part of it, but the biggest culprit is toxins, endocrine disruptors in our environment.

Matthew Cook, M.D.

Okay, so since we’re on the topic of testosterone, if we get down to the nitty gritty, I have a possibility of get putting a cream on, I have a possibility of doing an intramuscular injection, and then I have a possibility of doing pellets that could balance hormones. And now obviously, we have all of these other ones to think about, we’ll go to that next. But how do you make the decision between those? ‘Cause I think that’s a, from a urologist, I’d like to hear your perspective.

Tracy Gapin, MD, FACS

Yeah, yeah, great question. And there are a lot of docs out there who will say, “Hey, you need shots,” or “You need pellets.” They’re very black and white about it. And I really take a personalized approach where I’d like to share the pros and cons of each and give you reasons why you might wanna consider one over the other, and then I let the patient typically make that decision for themself. When we look at injectables, I actually find that sub-Q injections were just as well as IM injections of testosterone. And so most men have shifted toward the sub-Q injections. And that’s convenient ’cause you could do it right there in the belly next to the belly button, you could use a small insulin needle, the same supplies that they’re using for peptide as well. So it really makes it easy from a logistical standpoint to have just the same equipment for that supplies. 

So injectables, you could do as often as every day or as infrequently as once a week. Most of the time, I recommend at least twice a week, if not three times a week. And the rationale there is the more often you do it, the more stable your level gets. If you did shots once a month like some of these docs out there used to do, you get these big, huge peaks, and then it plummets and it stays low until your next big peak, and you get no real stability. The more frequently you inject, you can get a much more consistent stable level. And so now is where you get into the aspect of how compliant is the guy going to be. Is he willing to inject every other day, or is it really where he can’t stand the side of a needle and once a week is much as he can imagine? You weigh those pros and cons. With injections, the pros are that you can get very, very tight, very specific on the levels that you wanna achieve, and you can make microdosing adjustments to get the desired effect. And so-

Matthew Cook, M.D.

With that one, I’ll give you the two obvious downsides. One is the acne. And then two, that all joke is that sometimes, hormone replacement, especially when they go to those super high levels, like 15,00 people used to joke, there was a joke, it’s a great way to double your testosterone and lose half your money because they get kinda a little anger and little rage. And so people get divorced. That’s like a joke. But I think that within every joke, there’s a little bit of truth. Do you see maybe with the more stable levels of, without the bumps with the sub-Q, less of that, or have you experienced that, or what are your thoughts about those things?

Tracy Gapin, MD, FACS

I see zero issues with rage. I see zero issues with domestic abuse. I see zero issues with any kind of behavior change like that. Now, could you see that if you’re improperly dosing, if you’re taking steroids, if you’re doing other stuff? That’s a different story. But what I’m looking for is to optimize men’s hormones to the appropriate, healthy, optimal levels. And I’ll tell you, Matt, that I’ve never seen that in any guy that I’ve worked with for 20 years now. One of the things is important is that you monitor the levels appropriately and you get them to where you wanna be, and that you’re not trying to overshoot, and you’re not going crazy with it. As for the acne, occasionally, men have side effects. 

Every now and then, guys will have hair loss with testosterone. And that’s really more guys who tend to, and this is genetics based, have a higher conversion to DHT. It’s the DHT receptor where the hair loss activation that receptor where that tends to occur. And so some guys have hair loss, some guys get an acne, which we can actually treat. There’s a medication we can use to help with that actually. And then every now and then, guys will get swelling into low extremities and edema. Those symptoms are typically pretty rare, but I’ve honestly never seen a guy in my career, in my practice, have issues with rage or beating their wife or any kind of problems like that.

Matthew Cook, M.D.

Rage maybe is not the word. Where we used to see it, and I’ve never seen it really with the injectable or with a sub-Q, or with the creams, but where I did see it was, and maybe this is the next topic, we would see people that would do pellets, and then they would take people to 1,700 to 2,000. That was like, there was a motif. And I think that may have been a motif that I was seeing more-

Tracy Gapin, MD, FACS

Gotcha, yeah.

Matthew Cook, M.D.

Five or six years ago ’cause I’m not seeing it so much now. But if you could tell me about pellets.

Tracy Gapin, MD, FACS

Yeah, so pellets are attractive because they last for a long period of time. So pellets involve a guy or a woman, either way, lays on their belly on the procedure table, numb up a small spot in their buttock, make a little puncture, and with the little trocar, insert these tiny little pellets. And these pellets will slowly release testosterone over about four months, give or take. And metabolism’s gonna vary per individual, but about four months or so. And the beauty of that is for, especially men who travel. So I have guys who may be international travelers, and they can’t get back for months at a time. That’s where pellets are really attractive because guys can get dosed once, and it lasts for four months, and they have a nice steady state, and they’re happy, and it works well. The downside, the pellets, there’s always a con, the downside with pellets is that the dosing can sometimes be tricky. And so if I’m starting a guy, if he’s a brand new virgin, just getting started on testosterone therapy, I’m really not excited about starting with pellets because I don’t know what his body needs for testosterone, like what his requirements are, and everyone metabolize it differently. And so dosing can sometimes be a challenge if someone’s never been on testosterone therapy before.

Matthew Cook, M.D.

Okay, that’s a good one. So then now, we’ll put a bookmark in this, and that’s gonna be a nice dovetail to peptides. But before we go there, you mentioned the thyroid hormones. When you hear about functional medicine, there’s, I would say one category people would says, “Well, if we just balance those hormones, everything’s gonna be okay.” There’s another group that would be a big group that says, “If you balance the thyroid and fix the thyroid, a lot of other things start to come into place,” which I would also support and agree with. Tell me your thoughts about thyroid health, the thyroid, and how that comes in your practice.

Tracy Gapin, MD, FACS

Yeah, I’m glad you brought that up because I feel, in men’s health, it’s really overlooked. And a lot of guys don’t even check the levels, they don’t care about the levels. Their doctors will just check TSH. We’ll talk about that in a second. But a lot of guys aren’t aware of the fact that suboptimal thyroid hormone levels can contribute to symptoms like low energy, fatigue, brain fogs, low metabolism, poor muscle development, obesity, difficulty burning fat, losing weight, poor sleep. Sounds a lot like low T, doesn’t it? Yeah, because the symptoms are nearly identical. And so it can often be mistaken for just low T. Again, we come back to the systems approach to health. You got to look at all of these inputs into our complex human system and not just focus on any one piece. And so focusing, diving deeper into thyroid now. For the listeners, TSH, which is thyroid-stimulating hormone, is produced by the pituitary gland. It is not an active hormone. It is a signaling molecule that tells the thyroid gland to thyroid hormone. 

So again, TSH has no biologic activity other than to tell the thyroid gland to make thyroid hormone, which it does. The thyroid gland will make predominantly T4. And it’s called that because it has four iodine molecules to it, so it’s T4. T4 is a pre-hormone. T4 is not the active hormone. It has an iodine molecule removed when it’s activated to turn into T3. Removing an iodine convert T4 to T3. It’s called deiodination. And there are actually genetics around the deiodinase enzymes and how active they are and how likely your body’s going to have the ability to convert that T4 into the T3. But nonetheless, T3 is the active biologically productive form of thyroid hormone. And so that T4 and T3 will then feed back to the brain and tell it, hey, we’re good. You can stop making TSH. We’re fine now. And that’s the negative feedback. 

That’s how that works. The problem here is that most Western medical doctors and endocrinologists that went to medical school with you and me Matt, who were in the same class as we were in, they still preach, just check TSH. And that TSH will give you all the answers that you need. If TSH is high, clearly if thyroid gland’s not responding, clearly not making enough thyroid, so we’ll give you thyroid. If TSH is low, clearly you’re making enough thyroid, you don’t need hormone. You’re fine. And so they’re using TSH as a surrogate. And I feel very strongly that that’s a big, big mistake for a number of reasons. Number one, TSH is nothing more than a signaling molecule. You’re not checking the actually active hormone. 

You’re only checking the signaling molecule. Number two, just because TSH is low, that does not mean that a thyroid gland has produced the desired amount of T4, nor does it mean that T4 has produced the desired amount of the hormone we really care about, T3. And so that’s the key there. The key is that you need to measure T3 specifically free T3, which just like testosterone, you want the free, unbound form of the hormone, that’s actually the biologically active form of it. And that’s what I measure. In my practice, I look at free T4, which has some effect, but really, mostly T3 is where we get the benefit.

Matthew Cook, M.D.

So then that’s why I always tell everybody that I came from the heart of the medical industrial complex. Yes, and we’re doing integrated medicine, but what you said just sounds like medicine. And so then that’s kind of the rub, you know? And so then, I would say like my interpretation of that, and I would agree with everything that you said, is that… It is interesting. It takes, they say that like a brilliant idea comes up and it becomes into the scientific literature. And then it’s gonna end up in this clinic or at some generic clinic in 20 years later. And so then, the reality is if you wanna have a thoughtful conversation about the thyroid, then you’re gonna have to check all of those things and understand those things just like if you wanna have a thoughtful conversation around testosterone, you’re gonna have to look and balance all of those things. And so then that’s essentially what we’re doing. 

Now then if you think about a really amazing player that came onto the scene, and I just can’t wait to hear you talk about this from a urology perspective, on the hormone replacement front. And I always say that in functional medicine, you have to figure out which gang you’re in. And the biggest gang has always been the hormone replacement gang. And so everybody was doing testosterone and growth hormone. And so then all of a sudden peptides came out, and so then suddenly peptides became a way that we could influence what’s going on on the growth hormone side of things. And for the most part, almost everybody that I know quit doing growth hormone as an injection, and then evolved into the kind of the peptide conversation. Take me through your perspective on this topic.

Tracy Gapin, MD, FACS

Yeah, thanks. So there’s a fun kind of cutting edge topic that really, I think is really where most practitioners who are involved in a peptide therapy start, and that’s the whole CJC and growth hormone kind of conversation. So when we think of this symphony that you and I were just talking about earlier, growth hormone is one of those hormones in that symphony, and we recognize that there’s a linear decline in growth hormone as we age. And we know that growth hormone is critically important for energy, metabolism, burning fat, building muscle, cognitive function, brain function, and so on. Again, the same sort of benefits that we see with thyroid and testosterone and some other hormones. Growth hormone was critically important. And so that’s why people used and abused growth hormone over the years because it was deemed to be this, quote, fountain of youth. 

And that’s a very appealing effect from taking growth hormone. But growth hormone itself has some detrimental effect that are worth pointing out. Number one, when you take growth hormone, you are turning off your own body’s production of growth hormone. So let’s go to how it’s produced like we’ve done with the other hormones. We have the pituitary gland, which is where growth hormone is produced, okay? We have above that, the hypothalamus, which is another part of the brain that releases growth hormone-releasing hormone, GHRH. And GHRH has two functions. One, it tells the pituitary, hey, make more growth hormone. Number two, it actually goes around the body and has pleiotropic effect in and of itself. What does pleiotropic effect mean? It means is like a key that works in multiple doors, multiple locks, it has multiple effects. It actually, this is something that most people aren’t aware of, growth hormone-releasing hormone actually has some of the same beneficial properties as growth hormone itself. 

And that’s a really key point here. GHRH is very valuable in tandem with growth hormone. So when you take growth hormone, exogenously, you get this big blast of growth hormone levels. Well, what happens to your GHRH? It turns off. The hypothalamus senses, I have growth hormone. We don’t need anymore. It turns off. You’ve now lost that GHRH effect that is so important in adjacent or next to in tandem with growth hormone. You also don’t have the diurnal, throughout the day, we have a variation in our growth hormone levels. And when you take exogenous growth hormone, you’re crushing that. You’re basically blowing out the water and your levels are high continuously, and your body is not made for that. That’s not a healthy, optimal way to have growth hormone levels improved or upgraded. And so we look at a marker. 

How do you measure growth hormone? Well, you can’t really measure the bloodstream very well, so we use a surrogate for growth hormone, which is IGF-1. IGF-1 is a growth factor that is used to measure indirectly our growth hormone levels. And so when we take growth hormone, we’ll see a massive increase in IGF-1. Well, IGF-1 actually has some of the same benefits as growth hormone as well. So what we really have here to back up is you have growth hormone-releasing hormone, growth hormone, and IGF-1. All three of them that have kind of the same beneficial effects together in tandem. 

And so that’s the pro. Now the con is this risk that growth hormone has an anabolic effect. It is stimulating growth of cells. And the theoretical, I wanna point out theoretical risk is cancer. Could it promote cancer? That’s really the biggest risk that people talk about. Is it theoretical? Yes. Is it proven? No. But that’s something to be aware of. And so when we look at, for example, a guy who has prostate cancer, I run into this a lot. That guy wants growth hormone, I’m not your guy. And that guy wants peptides to boost growth hormone levels, I’m still probably not your guy. In theoretical, but it’s a real potential risk.

Matthew Cook, M.D.

So let’s say, had a prostate cancer five years ago, had a prostatectomy, PSA is normal.

Tracy Gapin, MD, FACS

That’s different. That’s fine. That’s different.

Matthew Cook, M.D.

Let’s say they had prostate cancer, they got seeds. And they’re PSA is two, and it’s been stable there.

Tracy Gapin, MD, FACS

Yeah that’s totally fine. Yeah, what I really mean is that I see a lot of guys on active surveillance who have low to intermediate great prostate cancer that I will manage with active surveillance expectantly, optimize everything else. And actually, remarkably, those guys are okay to get testosterone. Let me repeat that. The guys who have low grade indolent, non-aggressive prostate cancer, studies show, it’s okay to give them testosterone to optimize their levels as long as you monitor their cancer closely, obviously.

Matthew Cook, M.D.

The two big conversations to me is the guys and prostate cancer and hormone replacement and then women and breast cancer. And there is some evidence that guys that get prostate cancer may trend to have lower testosterone, right?

Tracy Gapin, MD, FACS

Oh, yes. Huge, huge correlation. You’re absolutely right, Matt. And that’s a really a big misconception testosterone. Does not cause prostate cancer. Testosterone does not cause prostate cancer. Low testosterone is directly associated with a markedly increased risk of prostate cancer.

Matthew Cook, M.D.

Right, yeah. So then, this one’s, and so then now… So then, this one right here to me is, for me and you, I would like to be in contact with you and have this 10-year conversation with you. Because we’re living the lifestyle, so we’re gonna be practicing medicine for the, I wanna have a 30-year conversation with you.

Tracy Gapin, MD, FACS

Yeah, oh yeah.

Matthew Cook, M.D.

‘Cause what’s gonna happen is where we’ll see an interesting evolution of thought around this and just like there’s an association for cancer with lower levels of testosterone, which is gonna probably evolve for us into this idea that it’s okay to be, have a normal testosterone in and around that. Then there’s an analogous conversation on the growth hormone side that it’s a hypothetical risk, but it may be the people with the lowest levels may be more imbalanced, and it may be something about the imbalance of low levels that makes people susceptible. I don’t know.

Tracy Gapin, MD, FACS

Yeah, yeah, very interesting thought. Exactly, yeah. But coming full circle back to the growth hormone, I just wanna make sure we kind of tidy that up, that the reason peptides are such an appealing way to increase growth hormone levels is that we are helping, we’re stimulating the body, the brain, specifically, to produce more growth hormone through GHRH, by increasing GHRA levels, which is then stimulating the pituitary to make more growth hormone. And so that’s more of a natural, normal diurnal rhythm and a healthy way to optimize growth hormone rather than blasting it exogenously.

Matthew Cook, M.D.

Okay, so then now, I’m gonna take that. And so then now we’re gonna do a deep dive for my peptide people. Take me through the sort of the entry level first kind of part of this conversation that people will start to do is they’ll take what’s called CJC and ipamorelin. And so that’s two peptides and they put ’em together in the same vial. And then talk me through your thoughts on that, how you like to dose it, and then how and where they’re working and talk me through what’s happening there.

Tracy Gapin, MD, FACS

Yeah, when people first start peptides, this is probably the one that everyone starts with because it’s fairly benign. It doesn’t seem to cause any side effects, troubles. It’s amazing for sleep, by the way. You take it at bedtime, we’ll talk about dosing, but it’s amazing for sleep, amazing for energy, and naturally boosting growth hormones. CJC is a growth hormone-releasing hormone peptide. What that means is it will increase growth hormone-releasing hormone function to stimulate the pituitary, specifically the anterior pituitary, to produce more growth hormone. Ipamorelin works in a slightly different way. It’s a ghrelin mimetic, okay? It works on the ghrelin receptor in the pituitary. Now what this does is it turns off the brakes, okay? What I mean by that is there’s another hormone to make this even more confusing called somatostatin. 

Somatostatin sits there and basically turns off the pituitary. It turns off growth hormone. It suppresses it, okay? It gets in the way. It’s like the breaks, okay? Somatostatin is the breaks of the pituitary so the pituitary cannot make growth hormone, okay? Ipamorelin turns off somatostatin. It blocks somatostatin. It’s a double negative. It turns off the brakes, okay? That allows CJC to work its magic to work, again, GHRH to stimulate growth hormone production. And so that’s why the two of them in tandem are so beautiful in that they work through different mechanisms to achieve the same outcome, which has increased growth hormone production. And the benefit there also is that you have increased GHRH levels as well, which again, that pleiotropic effect is so important.

Matthew Cook, M.D.

Okay, amazing. Totally support that. So then how do you like to dose those?

Tracy Gapin, MD, FACS

So normal dosing for that is, it’s a 2,000 microgram ipamorelin and 2,000 CJC in a 1 ml bottle. And you’ll typically do 0.1 of… I’m sorry, excuse me, 2 ml bottle. 0.1 cc’s of that every night at bedtime. And bedtime dosing is important because you want to boost growth hormone production and the highest levels or the peak of your growth hormone production is when you go to bed. And it’s especially helpful for improving deep sleep. And so that bedtime dosing is really, really important. Now you wanna do it only Monday through Friday. So I will be sure to emphasize that when you’re doing CJC ipamorelin, bedtime, Monday through Friday, give your brain a break, Saturday and Sunday.

Matthew Cook, M.D.

If you got-

Tracy Gapin, MD, FACS

And could also dose, I’m sorry.

Matthew Cook, M.D.

Oh, go ahead.

Tracy Gapin, MD, FACS

I was gonna say you could also double the dose, take 0.1 in the morning and 0.1 at bedtime. And that’s an approach that’s more geared toward weight loss. So either approach, most guys do 0.1 at bedtime, but you could do 0.1 in the morning, 0.1 at bedtime.

Matthew Cook, M.D.

Right, yeah. And then there are some people that will do it three times a day. But I like the once or twice a day. And then there are some people that you’ll talk to that will like to do a higher concentration of ipamorelin. And so then there are different ratios. And so you like the one to one ratio, basically, the best.

Tracy Gapin, MD, FACS

I typically just do the one. Yeah, I do the 2,000 microgram combination, yeah.

Matthew Cook, M.D.

Okay. Now, I don’t know. You have an amazing practice, which is anti-aging, wellness, male wellness. The population of patients who have real significant complex illness can have side effects from CJC in ipa. Have you ever seen that?

Tracy Gapin, MD, FACS

What I’ve seen with CJC is some guys have gotten a rash in their belly to the point where they actually had to stop it. I would say this happens, I mean, five to 10% at the most have I seen. A local rash at the injection site, only not a systemic rash, but locally. And some guys get flushing in their heads for about 15 to 30 minutes or so, which goes away and is typically when they first start taking it, which tends to resolve with time. But I have not, in my practice, had more severe reactions than that.

Matthew Cook, M.D.

What do you think that mechanism of that flushing in the head is?

Tracy Gapin, MD, FACS

Great question, Matt. I don’t know if it’s a filler or something in the product itself. It should be pure CJC-ipa. So I can’t imagine that’s the case. I don’t know. Do you?

Matthew Cook, M.D.

Well, it is something that I’m sort of trying to figure it out because basically what you just said, and I think this is an important thing for people to hear, and which is that if you’re a healthy 50-year-old guy with basically no problems and then you come and you kinda get in under this program and we’re balancing thyroid and testosterone, and there’s little things that happen, but almost never does anything go sideways, and you might get a little flushing, and that flushing goes away. And I think that that’s because these hormones have receptors on blood vessel walls. And so then that flushing is potentially, it’s activating those receptors, but you’re potentially also healing those walls. And so I think that there’s, potentially, it may be part of a beneficial process. If you look at… I’ve had some very significantly ill patients who have like Lyme disease or mold, and then that’s a whole nother sort of can of worms. And then interestingly, that population will have dysautonomia. And so then one of the things that happens with them is that they have POTS, which stands for, basically, when you stand up, you get low blood pressure. It stands for postural orthostatic hypotension. Those people, if you give ’em CJC will get flushing. And sometimes that flushing will last for like a week.

Tracy Gapin, MD, FACS

Wow.

Matthew Cook, M.D.

And so then, this is just one of my little pet projects that I’m sort of trying to figure it out. And what I have. And now, interestingly, and then this is a really interesting one. Like, for example, we take care of the patients with mold. And they have basically a real inflammatory sort of pattern, both in their blood and in terms of their genetic transcriptome. And so all of these aspects, you can’t give those people VIP until they’ve gotten better. So you don’t give them VIP, the peptide that regulates the brain until there’s a marker. They do this vision test called the visual contrast sensitivity test. And once that comes down and there’s not inflammation around the optic nerve, and then they’re better. Then at that point, then they can start to do this peptide VIP that fixes the mold. And so then interestingly, I’ve had people who were sick on the mold and Lyme spectrum, and they couldn’t take CJC, but then they got better. 

And once they were better, they took it fine. And so because this is like, you’re better than anybody I’ve talked to up until now at describing this stuff. And so I say this just as a backend part of the conversation. So people hear that if that flushing in sick populations may mean that you might wanna think about trying 1/10 of a dose and then working your way up. Or it might be that someone had a reaction, but then once they get better, they still end up doing great with it as part of a strategy, but it may mean that they need to see you for their thyroid and their lifestyle and all of these other factors while they optimize and kind of balance all of those other things. And then you can add the peptides for the growth hormone end.

Tracy Gapin, MD, FACS

Yeah, that’s fascinating. I appreciate you sharing that. I’ll tell you this. This really highlights a couple things. Number one, that this is end of one medicine. And I think it’s really important to point out that we talked about the systems approach and how peptides are the icing on the cake, that if you don’t have that foundational aspect of health first, if you haven’t cleared chronic inflammation and infections and mold, et cetera, then you should not be adding peptide. You should not be adding… These are not just performance enhancers you can add until you’ve done the foundational work first. And this also shows that I don’t work with Lyme and mold patients. I don’t work with patients who are sick like that, so I haven’t experienced that at all in my practice. And that just shows that everyone’s gonna respond so differently to these peptides. And we can look at the basic science of what they’re supposed to do and how they’re supposed to work. But in fact, like you point out, some people respond very, very differently, and we need to be cognizant of that. So I support you on that.

Matthew Cook, M.D.

So then, now then, move on to one of my favorites. So, if in terms of helping with growth hormone, the CJC and ipamorelin, the next one is tesamorelin. And tell us about how does that work, what are your thoughts on that and how do you like to use it.

Tracy Gapin, MD, FACS

Yeah, so I… Tesamorelin is like CJC-ipamorelin on steroids. It is taking it to the next level. When you look at CJC-ipamorelin, we talked earlier about IGF-1, and that combination, that peptide does not tend to really affect your IGF-1 levels very much. Now, is that because it has a less aggressive effect on growth hormone? Yeah, it’s a milder form, if you will, of optimizing your growth hormone production. Tesamorelin is gonna raise your IGF-1 by about 150 points. Now, that’s not as much as if I was blasting with growth hormone exogenously, but that’s a pretty high, that’s a pretty dramatic change over a very short period of time in your IGF-1 levels. And so I do see the value, the benefit of tesamorelin is great for, guys talk about shredding, they talk about being able to burn fat, build muscle very quickly. And it doesn’t have a very anabolic effect. So it is appealing in that essence. I like to cycle it. I’m very careful here. Well, I love CJC-ipamorelin long term, but then I’ll cycle tesamorelin for four to six weeks, and then I’ll go back to CJC-ipamorelin for, let’s say, three months or so and then cycle the tesa because it does provide some great benefit, but I don’t want turn off IGF-1 for prolonged periods of time like that.

Matthew Cook, M.D.

Okay, that’s good. I also will cycle. And so then sometimes, a little bit longer, sometimes, a little bit shorter. And so then we’re very, very similar. What do you think it is in the mechanism that helps it work more effectively?

Tracy Gapin, MD, FACS

You know, I actually don’t know the answer to that. I don’t know why it is that it’s more effective, why it has a much more intense effect than ipamorelin. Yeah, do you?

Matthew Cook, M.D.

I’m not positive. Do you know why? And when you use it, do you use tesamorelin by itself or do you use the tesa-ipa combination.

Tracy Gapin, MD, FACS

Yeah, yeah, I use it by itself typically, yeah.

Matthew Cook, M.D.

Oh, okay. So then we will use, a lot of time, a tesa-ipa combination. And so then, and interestingly, I found like the anabolic and then for working out, I like to take it in the morning before I work out. Is that also for you?

Tracy Gapin, MD, FACS

Yeah, I think, either way, some guys do it in bedtime, I think, you do in morning as well for training. Either way is okay, yeah. I will emphasize on the tesa that’s six days a week. So CJC-ipamorelin, five days a week, breaks Saturday on Sunday, typically, any five days you want. Tesa is six days a week, and I do one day of rest during that cycle.

Matthew Cook, M.D.

And a lot of those, I think, evolved out of people. People started doing this. And the story that I heard as people just kind of came up with that as an idea, well, let’s give the body a break. And so then, that came out of a conversation at a conference a number of years ago. And so then, but I like the idea of not doing something every day and taking breaks and cycling. And so then, I’m constantly sort of in a similar mindset. So then, in terms of, maybe we’ll kind of continue on in peptides that affect the brain ’cause we’re thinking about the brain and neurological function. From a perspective of neurological function, what are your favorite peptides? And then how do you tie them into kind of men’s health?

Tracy Gapin, MD, FACS

Yeah, great question. So when I do with men’s health, I don’t do a lot of work with traumatic brain injury sort of stuff. I don’t do a lot of work with dementia, typically, but I do see a lot of guys that have anxiety, memory issues, cognitive function, reduction, brain fog, that sort of stuff. So that’s where we look at peptide like Selank. I like Selank nasal spray. It’s actually part of an immune package as well. It does have an immune modulatory effect as well. But I use it more commonly for anxiety, does have a little bit of memory as well. Semax is good for memory as well, and then Dihexa, like Dihexa when we’re looking at memory. There’s a new, looking at Cerebrolysin is next one, looking at cognitive function of memory. There’s a new oral one out, and I won’t name the manufacturer, but I’m currently testing it myself before I could recommend it to others to see if it truly does have an effect. I’m not sure if oral dosing, what the absorption is like or bioavailability of it, but-

Matthew Cook, M.D.

Which peptide?

Tracy Gapin, MD, FACS

Cerebrolysin, yeah, it’s called, well, I won’t say what it’s called. But it’s an oral form of Cerebrolysin that has come out recently that I’m testing myself. Before I give it to anyone else, I got to be sure that I could see some benefit from it.

Matthew Cook, M.D.

Yeah, so it’s interesting. I just got a new patient yesterday who was on that, and I hadn’t seen that. And so then I’m gonna try that one. Yeah, that one is, most of these are synthesized. Cerebrolysin is actually an animal-based product.

Tracy Gapin, MD, FACS

It’s an isolate, yeah.

Matthew Cook, M.D.

Yes, an isolate, which I have liked over the years. And these days is kind of difficult to get. But then, we have clinics internationally, and we’re internationally sort of focused in these conversations because the regulatory environment, people listening to this just have to focus on the regulatory environment that they’re practicing in and the country that they’re living in. But it’s all over the map. So we’re evolving into kind of a new space, I think, in these topics where in different parts of the world, different things are a available and legal. But I wanna echo what you said, which is that the only thing that seemed relevant vis-a-vis a conversation like this 15 years ago for both of us was what does the randomized clinical control trial say, you know? And now, our approach is so multimodal. Okay, brain fog, could be thyroid, could be mold, could be low testosterone. So then we’re playing with a diversity of things ’cause almost everybody has a diversity of things. And then we’re working on kind of balancing and creating homeostasis. 

And then within that homeostasis, then we’re trying these things on ourselves and on our patients. And it’s a different way to practice medicine because I like to say there’s nothing that I do that I don’t do to myself. And the further that you go with that, you get fairly intuitive with how you feel on that. And it helps me, like, I love that you said, “I’m trying it on myself.” You’re not even talking about what it is because you’re trying it. I do the same thing every day. Like I tried four things today. And I was like, oh, like I did nitric oxide lozenge. And so then I was, I did the lozenge and then nitric oxide relates to kind of blood vessel dilation. And I loved these lozenges. And I took it, and then all of a sudden, I just felt like an incredible sense of wellbeing while I was doing my consult this morning. And my voice got a little deeper and richer. And I was like, oh, oh, that’s a good one. It’s kinda, I don’t know, that’s kinda cool.

Tracy Gapin, MD, FACS

Yeah, you bring up the point, and this program that I run. I run a comprehensive integrative program that incorporates medical management with peptides, with wearable tech, with genetics, with health coaching, fitness coaching, all these pieces that I integrate together. And you know what I call it, Matt? It’s called my N1 program.

Matthew Cook, M.D.

Oh, cool.

Tracy Gapin, MD, FACS

And it’s called N1 specifically for what you just discussed. And that is that this is end of one medicine. Everyone is so uniquely different. And all of these inputs that are affecting you may affect me very differently. And so it’s understanding how you’re responding. And that’s, to me it’s fun. It’s like a puzzle. Every patient is a puzzle, and how do the pieces inter interlock with each other, and it’s fun. It’s exciting to approach each patient, understanding the basic science behind these peptides, but understanding that everyone’s different and they respond differently. And the studies are in pharmaceuticals. When you have these pharmaceutical companies that could spend hundreds of millions of dollars on research studies until they get the one that proves their drug works, then they can market it and say, hey, look at the study, that works. The there’s no one out there doing a Dihexa study on memory. There’s no money there. And that does not mean that Dihexa is not amazing for memory.

Matthew Cook, M.D.

And Dihexa is a nice one people because that one’s a cream that you can rub on. Tell us about Dihexa, a little bit about the biology of it and how it helps with memory.

Tracy Gapin, MD, FACS

Yeah, I find, I’ve actually using myself for memory. I can’t actually, at the moment, pull out the basic science behind the mechanism of action of it. I just know that I used that, I think it was 20 milligram per ml cream, and it’s amazing. Yeah, perhaps you can enlighten me on the basic science there.

Matthew Cook, M.D.

God, I forget the… So Dihexa will actually improve, has some benefits on mitochondrial function and cellular efficiency. And so as a result, it’s driving cell efficiency. And I think that is what leads to the cognitive benefits. God, I literally look at this like three weeks ago, and I kinda… You talked about BPC. What’s your thoughts on that? And when do you like to use BPC?

Tracy Gapin, MD, FACS

Now, I love BPC. I tell you what. It comes as both an oral peptide, as well as a sub-Q injectable peptide. And the oral is, and first of all, BPC is derived from gastric enzyme from stomach juice enzymes. And so its benefit is typically seen in reducing inflammation. And that could be gut inflammation. It could be issues with musculoskeletal inflammation, it could be systemic chronic inflammation. But that’s really, it’s targeted use of action. In general, it’s believed that the oral version is better for gut inflammation, whether it’s irritable bowel, whether it’s potentially leaky gut, Crohn’s, that sort of stuff. And the sub-Q injectable is more for systemic inflammation. You could even inject sub-Q near a joint to get better local anti-inflammatory effect. I love BPC. I have found for myself, personally, that even the oral will often help me with musculoskeletal inflammation, which does not make sense. And people say the oral should not affect your joints. Sub-Q is the preferred route to affect musculoskeletal inflammation, but I see benefit with both. And so I use both oral and sub-Q my patients and on myself. And I think it’s a great drug for, I shouldn’t say drugs, excuse me, a great peptide for reducing inflammation.

Matthew Cook, M.D.

One thing that I will tell you, we do a lot of musculoskeletal medicine. And the interesting thing is that there’s a fairly high concordance of people that have leaky gut, and inflammatory gut problems, and musculoskeletal things. And so maybe that BPC. And have you ever seen some of the combinations that BPC and KPV together?

Tracy Gapin, MD, FACS

Mm-hm.

Matthew Cook, M.D.

So then, and KPV is actually a segment of the growth hormone is this mechanism. And interestingly KPV also some benefits for mast cell. So that combination can be a real nice anti-inflammatory gut stack. And so then it goes to show you, if you think about it the way we used to think about it, well, okay, BPC sometimes works in the gut, sometimes it works. If it’s orally, sometimes it works, sometimes it doesn’t. And so then you go, well, okay, why is that? Okay, well, maybe that’s because it works on the people who had leaky gut and the leaky gut was the cause of their musculoskeletal problem. If that wasn’t the cause of their musculoskeletal problem, you may wanna inject it subcutaneously, or it may actually be absorbed. So it’s like that process of thinking is kind of helpful. And then as a patient, as you’re working through it. In terms of like as, when you’re working with people who might have prostatitis or some of the straight up urology problems, have you been using peptides in that area?

Tracy Gapin, MD, FACS

I do, and I’ll actually use, for those guys, I’ll use sub-Q BPC for those guys as more of a systemic anti-inflammatory effect. A lot of those guys with prostatitis is non-bacterial and it tends to be more inflammation. And so I have used BPC with some success, not in every guy, but it definitely does help.

Matthew Cook, M.D.

Now, in terms of, for guys in sexual health, are you doing P-shot? Are you doing PRP to the penis? Or are you doing shockwave? How’s that going on?

Tracy Gapin, MD, FACS

Yeah, when we look at sexual health from a regenerative perspective, we have all the band-aids, the TriMix, and the pills, and the vacuum and all that kind of stuff. But when we’re looking at regenerative approaches, I do a fair amount of PRP, I do a lot of GAINSWave therapy as well. I love the combination of the two. And then there are some off-label non-FDA uses of some other stuff that I probably shouldn’t talk about here on this summit, but there’s some other regenerative treatments that we can use for that as well.

Matthew Cook, M.D.

Okay, yeah. So I’m a fan of regenerative things for the sexual health. And I’ve actually been doing… So then, in the penis, if you think of the anatomy of the penis, it looks like a double barrel shotgun. And that’s basically the part that fills up with blood and then underneath is the urethra. And so then, one thing that we’ll do is we’ll inject something into that thing. It’s called the corpus cavernosum, but it’s basically kind of like where the blood flows in the penis, and we’ll put PRP in there. I’ve had a lot of success with using peptides there. And have you ever done that?

Tracy Gapin, MD, FACS

I’ve heard of that. I have not done it myself yet. That’s next level. That’s pioneer level.

Matthew Cook, M.D.

Yeah, you know what? It’s funny because who I did it for was doctor friends of mine that had erectile dysfunction. And I wasn’t gonna talk about it, but then you reminded me because the band-aid and I like that you said the band-aid is these medications called TriMix and BiMix. And tell people what those are.

Tracy Gapin, MD, FACS

Yeah, so first of all, what was the peptide you used for the intracavernosal injection?

Matthew Cook, M.D.

Okay, so you can use BPC-157, you can use thymosin beta-4, and you can use BPC-157 and thymosin beta-4 together. I think that’s probably the best. You can use a fragment of thymosin beta-4. The fragment one to four works well. And then I’ve used GHK. And that’s a connective tissue peptide. I don’t use the GHK with the copper, but just GHK without copper.

Tracy Gapin, MD, FACS

So you did TB-4 with the BPC is what you’re saying? I was wondering which one you did.

Matthew Cook, M.D.

So that was the, that was the first thing that I started doing. So I started doing that about three years ago. And so then I had guys, and so then this will be a good one for you to go back into. So the first, let’s say you come in and you go, oh, okay, erectile dysfunction. And so it’s not working that well. And so then the first thing is, let’s take Viagra or Cialis. So then that works, works, works, and then that stops working. And so then the next thing is potentially, people start to do some other things and those fail. And so then, they go to urologists, and that urologist will put them on an injectable. And this is where they’re actually injecting into the penis. And the medications are BiMix and TriMix. And so tell us about those.

Tracy Gapin, MD, FACS

Yeah, so what we’re doing here is we’re trying to use the phrase band-aid ’cause these guys, while were working on regenerative approaches, they wanna have sex right now. They don’t wanna wait three months until we get a good blood flow working. And so when the pills, as you mentioned, Matt, when Viagra and Cialis don’t work, vacuum pump doesn’t work, they don’t like it, injectables are a great way to stimulate an erection on almost any guy anytime. And so we look at drugs that will increase blood flow to the penis. And so papaverine, phentolamine, and prostaglandin E. Those are three injectable agents that will all cause vasodilation or widening of the arteries to allow increased blood flow in the penis, which is really the hallmark of an erection. And so papaverine and phentolamine, together, is called BiMix, two drugs together, or papaverine, phentolamine, and prostaglandin E is called TriMix. And then you can even add atropine for QuadMix for guys who need more help, and you could do super TriMix, which is a higher concentration of those drugs as well. But those are the drugs that are mixed together as an injectable, what I call band-aid to get you an erection like right here, right now.

Matthew Cook, M.D.

Okay, good one. So then what happens with those who’s somebody that has erectile dysfunction and then the medications stop working. You inject those and then that vasodilates all the veins going into the penis, then it can lead to an erection. So then, I ended up having some friends who were doctors who basically were doing TriMix, and BiMix had worked for a while and then BiMix will stop working, and so you move him onto the TriMix. And so that had stopped working. And so then this was basically, this was kind of revolutionary for me to do this, but what my logic was they came to me, we’re gonna go get a penile implant because that’s the next thing that a urologist would do sort of on this road. And so then sure enough, I started injecting BPC. And then when I do the P-shot, I do it with an ultrasound. 

And so then you can look and see, and so I stick, there’s a little artery over on the medial side. So I stick the needle in and then when I stick it in, I stick it in and it’s just a 30 gauge needle. So this is a tiny needle. It doesn’t hurt at all. And then what was very interesting for me because when I injected the thymosin beta-4 and the BPC, I had heard that you could do this and people had done it, you inject it in. And then what happens is immediately, you see the whole penis start to vasodilate. And then it starts on the, if you come in on the right side, it you’ll see the right side dilate. And then what I do is I go to the other side of the table and I inject the other side. 

But by the time I get to the other side of the table, they’re both totally dilated. But I do an injection on each side, just so that it’s balanced, and I have the same amount of medication that I’ve put on both sides. And then what happened is basically, almost everybody that I’ve done this for, when they go from being on TriMix back to BiMix. And then I got guys that then suddenly, they start now, Viagra starts to work. Now the logic here is that just what you said, we’re trying to bring blood flow back. And so then now we’ve got a diversity of solutions and a diversity of sort of things to begin to try. And then interestingly, if you say, what do I think is the future, I think the future is, and I have had people do this successfully is to get to where you’re using BiMix and TriMix, but then you start to intersperse and do peptides instead. And this is, I wasn’t gonna go into this, but to me, this is the future of urology. And so I literally can’t wait to talk to you next time I talk to you and hear your evolution of thought around it.

Tracy Gapin, MD, FACS

Yeah, I’ve heard of this, and I’ve been a little reluctant to introduce them to my practice, but now you got me excited. I’m gonna out there and whoever the next guy is, he’s gonna have a conversation with me about it.

Matthew Cook, M.D.

Yeah, it’s very safe and I’ve never had a problem with it. And then I can kind of talk you through the dosing. And the dosing can be low dose. The dosing can be high dose. So I’ve got quite a bit of thoughts around it and-

Tracy Gapin, MD, FACS

Nice.

Matthew Cook, M.D.

So anyways, well, it is a 100% pleasure to talk to you. I feel like we covered some interesting ground, some new ground. But if you live in Sarasota or if you’re a guy and you live anywhere and you wanna have a thoughtful, amazing physician take care of you, then I encourage you to call Dr. Gapin, like gap, and he’s gonna take awesome care of you.

Tracy Gapin, MD, FACS

I appreciate it, Matt. I enjoyed it. This is a fun conversation.

Matthew Cook, M.D.

Awesome. Thanks a lot.

Tracy Gapin, MD, FACS

Okay.