Last month you may have noticed some men growing beards and mustaches as if it were a competition. It was ‘Movember’ last month – a month of facial hair growing in honor of men’s health issues. In general, women tend to be much more interested in health and so I found it quite refreshing to see men actively involved in the name of men’s health issues. To further honor the men, this month’s article is part one of a two part men’s health series. In part one I will go over andropause and testosterone therapy.
Disclaimer: Ladies, if you’ve had trouble getting your husband to see his doctor I hope this article will help but can’t guarantee it! If your husband is like mine it is a near miracle to get him in – especially if there’s a needle involved!
What is Andropause?
Andropause or decline in testosterone production usually starts around age 50. For some, unfortunately, it can start much earlier. Signs of low testosterone are usually pretty evident if one knows what to look for. Sex drive drops, appetite for life wanes, muscle mass may seem to disappear despite efforts to maintain it. In some excess fat will deposit around the midline and sometimes in the chest area, and men can become noticeably grumpier. Less visible or noticeable, bone density can drop – leaving older men at risk for fractures. Some men may even experience hot flashes much like women do during menopause. Even elevated cholesterol can be partly due to drops in testosterone levels.
Although we expect testosterone levels to drop as men age (along with many other hormones), as this happens chronic illness starts to increase. For many men the addition of supplemental doses of testosterone to maintain healthy blood levels allows aging to be a healthier experience with better quality of life.
Treatment:
If blood testosterone levels are low, I generally recommend using daily doses of topical testosterone in the form of a cream. The benefits of topical creams are; one can administer it oneself, levels of testosterone will be the same day to day, and it works for most men. If testosterone cream does not get blood levels up, then injections in the office are the next best-thing. Other less often used options are patches and pellets.
Does one use testosterone forever? It’s fine to stay on testosterone for years – there are many health benefits – but you can stop whenever you want. However, your symptoms will return eventually.
Increasing the body one testosterone production
Testosterone can be increased with injections of human chorionic gonadotrophin (Hcg) a couple times a week. This usually works better for men under age 50 and does not require following a low calorie diet - but can be if obesity is also an issue. This is the treatment of choice for men wishing to maintain fertility/actively trying to get pregnant.
Benefits of Testosterone
There are receptors for testosterone all over the body in men and in some degree in women. Because of this, testosterone has beneficial effects all over the body!
Restoring normal testosterone levels has been shown to improve bone density – especially important for men over 60.
Risk of heart disease is lowered with maintained levels of testosterone. Testosterone can also lower total and LDL cholesterol. It has been shown to have anticoagulant (blood thinning) properties. Studies have also shown that testosterone reduces angina pain and lowers levels of CRP - a heart disease risk factor related to inflammation.
Men with issues of impotence and low libido also benefit from testosterone therapy. Several studies have shown testosterone can help men who have not responded to Viagra. And it is likely to help men who have not responded to natural alternatives to Viagra as well.
Testosterone has anti-inflammatory effects. Low levels are associated with higher incidence of rheumatoid arthritis in men.
Testosterone also increases tolerance to pain. Men on long-term opioid (Morphine, methadone) treatment for chronic pain have lower levels of testosterone, making them more sensitive to pain. For these men testosterone will reduce pain and improve quality of life
Mood is generally greatly improved with testosterone. Men report a better sense of vitality, more motivation and less irritability after replenishing levels of testosterone. Studies have shown reduced anxiety and better cognitive function after replenishing testosterone levels in animals.
Prostate cancer risk is reduced by maintaining healthy testosterone levels. I’ll discuss this a bit more below.
Testing
Beyond testing just testosterone (free and total), estrogen and PSA levels in the blood, we can pick up some very valuable pieces of information about a man’s endocrine health and prostate cancer risk with a Testosterone Metabolite test from a specialty lab. This test allows us to see if 3beta-Adiol levels are too low which translates into higher risk of prostate cancer. 3beta-Adiol levels are decreased by medications for benign prostate enlargement – Proscar and Avodart are two examples. To avoid this in the first place I generally recommend natural therapies that work just as effectively without causing the increased risk of aggressive forms of prostate cancer.
For men with male pattern hair loss or benign prostate enlargement testing blood levels of DHT (dihydrotestosterone) can be help identify other treatments that will positively impact these issues.
Often men with low testosterone will have low bone density so it is a good idea to have a bone density scan if testosterone is low on lab tests.
A complete blood count or CBC should also be checked routinely to make sure red cell count doesn’t get too high which can make blood ’thick’.
Precautions
Testosterone therapy does not come without precautions. Excess testosterone levels are not ideal. If this happens often men will notice mildly increased aggression, acne, and possible fluid retention and very occasionally elevated blood pressure readings. Blood can also become thick with increase blood cells. A milder issue but equally concerning is excess conversion of testosterone into estrogen. Men with diabetes or insulin resistance are at increased risk of conversion into estrogen. We always test estrogen and testosterone at check-ups to monitor this. There are medications called aromatase inhibitors to address this but we can usually take care of it with Chinese herbs in capsules taken daily. Testosterone will also reduce fertility in men and can reduce testicular size – although this is not usually noticeable for most men. If a man is trying to have more kids we generally will postpone treatment or use other methods to raise testosterone until the wife is pregnant and then we can start testosterone.
Testosterone and Prostate Issues
Many doctors will not recommend testosterone for men with BPH due to outdated thinking that testosterone will further enlarge the prostate. There is no scientific basis to this concern. Conversion to estrogen on the other hand is. For men with BPH that start testosterone therapy due to low levels, I will always start herbs to prevent this conversion.
In regard to prostate cancer, in the past, doctors thought that testosterone increased cancer growth. After further investigation it was found that low testosterone levels contribute to increased risk of prostate cancer. Estrogen, not testosterone fuels prostate cancer growth. Doctors often find that PSA will decrease more often than increase after starting testosterone. Because of this, I generally think of testosterone replacement as a cancer prevention measure, especially with the addition of testosterone metabolite testing.
If you’d like to read more about this topic I highly recommend the book “Testosterone for Life” by a Abraham Morgetaler MD. This book is written by a Harvard MD and has a great chapter on testosterone in regards to prostate cancer. It is also a wonderful reference for men (or women) who want to know more about testosterone replacement therapy.
In part two of the men’s health topic we will explore prostate health and prostate cancer further.