Testosterone Therapy in Men
Testosterone Replacement Therapy for Men
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:
- Low testosterone levels in men have an adverse effect on incidence of stroke, heart attack and peripheral arterial insufficiency.
- Testosterone levels are inversely associated with risk to stroke. Men with lower levels have a higher risk to stroke. In addition, recovery is better in men with higher levels of testosterone.
- Testosterone levels are inversely related to myocardial infarction (heart attack). In patients with angina, dosing with testosterone improves exercise performance. The time to onset of chest pain during an exercise stress test is lengthened.
- Patients with peripheral arterial insufficiency show a marked improvement in symptoms with testosterone therapy.
- The cardiovascular disease benefits attributed to testosterone occur because testosterone improves the clotting parameters of the blood. It makes the blood less sticky and more slippery.
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 AND SYMPTOMS OF TESTOSTERONE DEFICIENCY IN MEN
Signs of Sexual Dysfunction:
- Decrease in spontaneous early morning erections
- Decreased libido or desire for intimacy or sexual activity
- A decrease in the fullness of erections
- Difficulty in maintaining an erection
- Difficulty in initiating an erection or unable to achieve an erection
- Decrease in volume of ejaculate
- Decrease in the strength of climax or force of muscular pulsations
- The feeling of being burned out
- Symptoms of mental fatigue and difficulty in concentrating
- Fatigue most marked in the early afternoon or evening
- A decrease in mental acuity (sharpness, wit)
- A reduction in creativity or spontaneity
- A decrease in initiative or desire to start new projects
- A decrease in interest in hobbies or new work-related activities
- A decrease in competitiveness
- A change in memory manifested by an increase in forgetfulness
- A sense of depression manifested by sadness, tearfulness, an inability to enjoy the simple pleasures of life
- “Sore-Body Syndrome” manifested by non specific muscle and joint discomfort
- Decline in flexibility and mobility; increased stiffness
- A loss of muscle size, tone and strength
- A reduction in stamina
- Reduced athletic performance
- Pain in neck, shoulders and low back
- An increased injury rate with a slower recovery/repair time
- The development of inflammatory arthritis such as rheumatoid rthritis in mid or late life
- The development of osteoporosis; bone thinning
- An increase in total cholesterol and or triglycerides
- A decrease in HDL; the protective transport protein
- Insulin resistance or overt Diabetes
- Blood pressure elevation
- Coronary artery disease; angina, heart attack
Additional Physical Changes:
- An increase in fat distribution in the breast and or hip area
- Unexplained weight gain, particularly in the mid section
Non-Specific Symptoms that may be related to low Testosterone:
- Symptoms of light-headedness, dizziness
- Ringing in the ears
- New onset of headache
- Changes in visual acuity
- Circulatory problems of the lower extremities
TESTING TO IDENTIFY ADROGEN DEFICIENCY STATES
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:
- Acid suppressing medications: H2 blockers (Tagamet, Zantac, Pepcid), proton pump inhibitors (Prilosec, Prevacid)
- Antibiotics: this includes bacterial antibiotics such as tetracycline, erythromycin, quinolones (cipro) and antifungal antibiotics such as fluconazole, itraconazole and ketoconazole
- Antidepressants: the SSRI drugs such as Prozac, Paxil and Zoloft
- Antipsychotics: this includes medications such as Thorazine, Haldol and related drugs
- Cardiovascular medications: beta blockers (propanolol, atenolol, metoprolol), anti- arrythmics (Quinidine, Amiodarone), Coumadin, calcium channel blockers
- Cholesterol lowering medications; this includes medications such as Mevacor, Zocor, Lipitor, Pravachol
- Pain medications such as acetominophen (Tylenol) and propoxyphene (Darvon)
- NSAIDS (non-steroidal anti-inflammatory drugs) such as aspirin, ibuprofen and others in this class
- Substances of abuse: alcohol, amphetamines, cocaine, marijuana
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:
- Zinc in a dose of 30-50 mgs per day
- Quercetin in a dose of 500-1000 mgs two times per day
- Chrysin in a dose of 500 mgs 3-7 days per week
Supplements that may inhibit 5-alpha reductase activity:
- Saw Palmetto in a dose of 320 mgs once daily
Supplements that improve the Metabolism and Excretion of Hormones
- Oncoplex-one daily
- Iodorol-one three times per week
Supplements that support Prostate health:
- Vitamin D in a dose of 2000 units per day
- Selenium in a dose of 200 micrograms per day
- Lycopene in a dose of 20 mgs per day
- Saw Palmetto in a dose of 320 mgs per day
- Oncoplex in a dose of 1 capsule per day
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:
- Hormonal imbalance
- Circulatory insufficiency from arteriosclerosis
- Blood fat abnormalities
- Neurological dysfunction in the brain or in the peripheral tissue.
- Psychological and or social problems
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.