Androgen (testosterone), therapy has received a great deal of attention in recent years. The intensity has elevated dramatically in the recent months. As a generation of Americans reach middle age concern mounts regarding the effects of aging on health and disease. Testosterone has been used since the first half of the 20th century. With time and experience we have developed a growing knowledge base about the benefits, risks and safety parameters in using testosterone therapy. The effect of testosterone on libido and sexual performance is of prime concern to the public. I am also interested in normalizing testosterone levels because of its other health benefits in the aging male.
Testosterone declines as we age. This is inevitable. The rate of decline varies from person to person and is in part due to individual genetics. A more significant effect on testosterone levels is the environment, diet, stress, and exercise levels.
Declining testosterone levels are shown to affect psychological and neurological function, cardiovascular function, musculoskeletal function and hormonal function.
Testosterone and Cardiovascular Disease:
Testosterone and Musculoskeletal Function:
Adequate levels of testosterone are necessary for maintaining muscle mass and bone density.
Hip fracture in elderly men account for one third of these events in the elderly. This is a disabling problem that is accompanied by a loss of independence and an increased risk to early death. Testosterone therapy has been shown to increase bone mineral density in men with osteopenia and osteoporosis.
Testosterone therapy has been shown to increase muscle mass and strength in men with testosterone deficiency and muscle wasting. This is profoundly important since adequacy of muscle mass and strength is essential to independent living. Independent, active living late in life is a prime goal of health aging.
Testosterone and Healthy Hormonal Function:
Proper glucose (sugar) metabolism is a key component of good health. Experts estimate that a quarter of the population has a genetic tendency to insulin resistance. This risk is independent of body weight, body mass index or obesity. It is primarily a genetic predisposition. Its manifestation is dependent on environmental factors such as diet, exercise and body weight. Insulin resistance promotes arteriosclerosis, impairs immune function and may even increase our vulnerability to cancer. There is an inverse relationship between testosterone levels and insulin resistance. Testosterone and DHEA supplementation (when appropriate) can improve insulin resistance and even help improve overt diabetes.
Testosterone and Psychological Health:
The psychological symptoms of androgen deficiency are varied and complex. Symptoms and conditions that can improve with testosterone supplementation include depression, anxiety, poor libido, sleep disturbance, poor self esteem and poor memory. Testosterone therapy is not the cure for these problems but it can be an important adjunct to a comprehensive therapeutic program.
Signs of Sexual Dysfunction:
Psychological/Mental Functioning:
Musculoskeletal Symptoms:
Metabolic Problems:
Additional Physical Changes:
Non-Specific Symptoms that may be related to low Testosterone:
The basic tests involve testosterone blood levels, DHEAS, estradiol and sex hormone binding globulin. These are blood tests best done in the morning when testosterone levels are at their highest. In complex situations I may order a 24 hour urine test that measures testosterone and its metabolic by products in order to understand how best to individualize treatment. A certain amount of testosterone is converted to estrogen by aromatase enzyme. When this conversion process is excessive, men with normal testosterone levels may appear to have either testosterone deficiency or signs of estrogen excess. When estrogen is elevated in relationship to testosterone certain dietary changes and supplements may be useful in correcting the situation.
Testosterone is converted to Dihydrotestosterone by 5-alpha-reductase enzyme. Excessive conversion is undesirable and can be managed with either dietary supplements and or prescription medication. The level of sex hormone binding globulin (SHBG) can affect the availability of testosterone to the tissue. Supplementation of hormonal agents by mouth may increase SHBG. Knowing the level can help direct therapy for the individual. One size does not fit all; one treatment does not fit all. Individualization of therapy is the key to an optimal outcome. Monitoring hormone levels, physical findings and patient symptoms should be done at 3-4 month intervals while on hormone replacement therapy.
MEDICATIONS THAT CAN CAUSE HORMONAL IMBALANCE:
The liver rapidly metabolizes testosterone. Supplements or prescription drugs as much as the level of estrogen do not affect the level of testosterone. Liver detoxification processes break down estrogen. This process is more complex and time consuming. It is more readily affected by prescription medication, over the counter medication and supplements.
Drugs that Increase Estrogen Levels:
These medications should not be avoided if medically necessary. On the other hand, there use should be minimized and alternatives should be sought that do not interfere with estrogen metabolism.
What is the point of spending money on expensive medication and going to the trouble of monitoring its effect if you are not going to make the life style changes that will optimize a therapeutic outcome?
Diet should be individualized based on background health issues. At the very least follow our general guidelines on diet and exercise as outlined on this website.
Supplementation with vitamins, minerals, therapeutic nutrients and herbal products can be an important part of a comprehensive program. Supplementation recommendations are individualized.
Testosterone is used as a transdermal cream. The potency of the cream is adjusted to achieve an optimal blood level of testosterone. Blood levels are checked at 6-8 week intervals until an optimal level is achieved. After that I recommend checking blood levels at 3-4 month intervals. In some cases alternative forms of delivery are recommended. Subcutaneous injections are a useful alternative. They are more effective and are particularly valuable for older men and men with acute problems such as peripheral arterial insufficiency.
Hormonal therapy is most effective when the complex interactions of all the hormones are taken into consideration and supplementation is balanced with this in mind. Diet and exercise issues are always important.
In many cases a prescription hormone is not necessary. We can improve the patients’ hormone balance and symptoms by manipulating diet and using non-prescription supplements. There are many examples of non-prescription supplements that may improve hormonal balance.
Supplements that may inhibit Aromatase activity:
Supplements that may inhibit 5-alpha reductase activity:
Supplements that improve the Metabolism and Excretion of Hormones
Supplements that support Prostate health:
Supplements that may Improve Sexual Function:
Gingko Biloba Extract, (GBE), has been show to improve impotence. The suggested dose is 120 mgs two times per day. You must take it for at least eight weeks to determine if it will be effective. In one study up to 50% of men showed improvement after six months of continuous use.
Peruvian Ginseng, (Maca), in a dose of one capsule two times per day may be helpful. This product is a general adaptogen derived from Peru. It was and is highly prized for its ability to improve vitality, desire, stamina and performance. One postulated mechanism of action might be by normalizing the hypothalamic-pituitary-testicular axis. The recommended dose is one capsule two times per day. Results may take up to three weeks.
Yohimbine is an extract of a tree, Pausinstalia yohimbe. It may improve sexual desire and erectile function. One proposed mechanism is interference with the alpha-2-adrenergic receptors form inhibiting erectile function. It also promotes blood flow to the penis. This supplement should be used with caution in people with hypertension. Yohimbine is actually sold as an FDA approved prescription medication. One must use an appropriate dose for 2-3 weeks in order to determine whether it will be effective.
Muira puama is an herbal product from the South American rain forest. The Indians who referred to it as “potency wood” traditionally used it as a sexual enhancer. In a European study 62% of impotent men had significant improvement after a two to four week trial of therapy. The mechanism of action is not known. There are no known side effects.
Plant Sterols such as Cholestatin have been shown to increase testosterone levels.
When dealing with issues of loss of libido, erectile dysfunction and ejaculatory dysfunction I recommend consultation with a health care practitioner. Possible causes of these problems include:
Often there are multiple causes; hence the value of working with a health care practitioner.
I am indebted to Drs. Eugene Shippen and Thierry Hertoghe. Their work in this field is thorough and based on solid science. I refer you to Dr. Shippens’ book The Testosterone Syndrome. This is an excellent read for the layperson as well as the health care practitioner.