Andropause, Hormone Balance for Men
1. Andropause comes from the Greek words andros, meaning male and pausis, to stop. Andropause refers to the decline of male hormones, mainly testosterone. Testosterone levels begin to decline in some men as early as 35 years of age. Typically, levels begin to drop between 45 and 55 years of age. Some men continue to have healthy levels of testosterone well into their 70’s and even 80’s. Unlike women, who may experience rapid changes in hormone levels, men experience a gradual decrease in hormones. As testosterone levels decline, there is deterioration of both mental and physical health. Testosterone therapy has been used for over 60 years. In fact, as far back as the late 1880’s people were using testicular extract from animals to treat the symptoms of testosterone deficiency. Ancient Indian, Greek, and Egyptian civilizations also used hormones for therapy. Diet and lifestyle are extremely important to hormone balance. In this presentation we will discuss how testosterone levels can be raised naturally by changes in diet and lifestyle. Each person must be evaluated and treated as an individual. Hormone levels must be tested and therapies customized.
2. Testosterone is an anabolic, or building hormone that improves muscle mass, including cardiac muscle, and bone density. It is critical for optimal brain function. Testosterone improves mental sharpness, concentration, and memory. It increases energy levels. Testosterone improves flexibility, mobility, balance, and coordination. It prevents aches, pains, and arthritis. Testosterone also increases sex drive and libido.
3. A normal testosterone level is protective against Alzheimer’s dementia, symptoms of Parkinson’s disease, and cognitive or mental decline. It helps to prevent diabetes and the complications of diabetes, including amputation. In fact, testosterone therapy has been used in Germany for over 40 years to treat diabetes. Testosterone protects against abdominal obesity, a risk factor for both heart disease and diabetes. Testosterone is a natural antidepressant. As levels of bioavailable testosterone, that is testosterone that is available to the cells, decline, there is an increased incidence of depression. Testosterone therapy was used in the 1930’s to treat men with what was described as ‘melancholia’ or depression. Testosterone protects against bone loss in both men and women. As levels of testosterone decline, the incidence of osteoporosis, falls, and fractures increases. Normal levels of testosterone prevent inflammatory conditions like Fibromyalgia and Chronic Fatigue.
4. As mentioned earlier, testosterone is critical for heart health. There are many testosterone receptors in the cardiac or heart muscle. A low testosterone level is an independent risk factor for Congestive Heart Failure. Low androgen levels correlate with CAD in men, whereas normal testosterone levels are associated with a reduced risk of heart disease. In China, doctors are treating men with ‘angina’ or chest pain due to blockage of the blood vessels to the heart, with testosterone therapy. Testosterone has been shown to dilate, or open up, the coronary arteries, as well as the aortic and brachial arteries. Testosterone helps to maintain healthy cholesterol levels. A low testosterone is associated with elevated LDL and TG levels and lowered HDL levels. There is also and inverse relationship between testosterone and BP. As testosterone levels decline, BP rises. Testosterone therapy can normalize BP.
5. Testosterone does not cause prostate cancer. In fact, low levels of testosterone are associated with more aggressive disease and worse outcomes (even in dogs). Normal testosterone levels may actually protect against prostate cancer. However, testosterone can stimulate an active cancer. Testosterone therapy does not cause liver failure. High doses of synthetic, chemical anabolic steroids, like methyl testosterone are toxic to the liver. These anabolic steroids can cause jaundice, liver cysts, and liver tumors. It is the synthetic hormones that increase LDL, suppress HDL, and increase the risk of heart disease, NOT testosterone.
6. DHEA or dehydroepiandrosterone is also an androgen. It is a precursor hormone to both testosterone and estrogen. Like testosterone, low levels of DHEA have been associated with depression, heart disease, and diabetes. Low levels of DHEA are also seen in autoimmune diseases like rheumatoid arthritis, Fibromyalgia and Chrohn’s disease. Low levels and high levels of DHEA have been associated with breast cancer. It’s all about balance.
7. Testosterone is converted to estradiol by an enzyme called ‘aromatase’. Estradiol can then convert to estrone, another strong estrogen. As men age, the ratio of estrogen to testosterone increases. It is the elevated estrogen to testosterone ratio that is a risk factor for both BPH and prostate cancer. Some authors feel that changing the ratio in favor of testosterone may offer protection to the prostate gland. It is not only the decline of testosterone but the increase of estradiol and estrone that cause the symptoms of Andropause. High levels of the estrogens increase the carrier protein called SHBG, which binds testosterone, making it inactive or unavailable to the cells, further increasing the symptoms of Andropause.
8. Symptoms of Andropause include mental fatigue, feeling ‘burned out’, and the inability to concentrate. Insufficient testosterone is a frequent cause of insomnia, not being able to sleep. Symptoms of Andropause include decreased mental sharpness and increased forgetfulness. Other mental status changes include depression, irritability, anger, and anxiety. Physical symptoms include fatigue, tiredness in the afternoon, aches, joint and muscle pain, decreased muscle mass, decreased coordination, and problems with balance.
9. Men may experience shortness of breath with activities. Low levels of testosterone may be associated with the development of chest pain, a diagnosis of heart disease, blockage of the coronary arteries, and rising blood pressure. Symptoms of Andropause include swelling of the ankles and varicose veins. Lightheadedness, dizzy spells, increased sweating, and even hot flashes are symptoms of male hormone deficiency. A declining testosterone leads to rising blood sugar levels, worsening of diabetes, incontinence, erectile dysfunction, and decreased libido.
10. Certain factors may contribute to testosterone deficiency. Mumps during childhood may affect testicular production of testosterone. Alcohol, stress, and obesity are not only associated with a decline in testosterone, but also an increase in estrogen. Many drugs affect the liver and lower the amount of testosterone that is available to the cells. These include the non steroidal anti inflammatories, Tylenol, aspirin, the statins, many heart and BP medications, antidepressants, H2 blockers, and chemotherapy.
11. There are many ways to raise testosterone and lower the estrogens naturally. Exercise increases the production of testosterone. It also decreases estradiol and the carrier protein SHBG, freeing up more of the testosterone, making it available to the cells. Loosing weight will decrease the conversion of testosterone to estradiol in the fat cells by the enzyme aromatase. Eliminating processed foods, lowering insulin levels and limiting alcohol will also raise testosterone and lower estrogen. A diet high in fruits, vegetables, nuts, seeds, and fiber will also raise testosterone, balance estrogen, and protect the prostate gland.
12. There are also supplements which raise testosterone and protect the prostate gland. Many of these, like zinc, vitamin C, Chrysin (with piperine added to enhance absorption), progesterone, and the flavones, work by inhibiting the enzyme aromatase similar to the pharmaceutical aromatase inhibitors, aminoglutethimide and arimidex. Many of these natural aromatase inhibitors are also potent antioxidants. Other supplements, like saw palmetto and nettle root, inhibit an enzyme called 5-alpha reductase which prevents the conversion of testosterone to the more stimulatory DHT. Nettle Root also binds to SHBG freeing up more testosterone. Nettle is used in Germany to treat BPH. Vitamin E, B vitamins, magnesium, omega 3 fatty acids, and whole soy foods are also protective of the prostate gland as is pygeum, pumpkin seed, and lycopene. Other supplements, like indole 3 carbinol, work by neutralizing the stimulatory estrogen metabolites.
13. Progesterone, like testosterone, in present in both men and women. It is a precursor to the adrenal hormones which include cortisol, androstenedione, and testosterone. Levels in men decline around 60 years of age. Progesterone protects the prostate gland and lower PSA. It not only inhibits aromatase but also 5-alpha reductase, raising testosterone levels and lowering both estradiol and DHT. It antagonizes the stimulatory effect of estrogen on the prostate gland and stimulates the anti-tumor antigen p53, helping to prevent prostate cancer. A low dose of progesterone may be part of male HRT.
14. Hormone testing may be done using saliva, urine, or blood. Both 24 hour urine and saliva are a reflection of testosterone that is available to the cells. A patient may have a normal testosterone level in blood but the amount available at the cellular level may be inadequate.
15. Saliva is collected in the morning. Profile I includes estradiol, DHEA-S, progesterone, bioavailable testosterone, and cortisol. I also measure estrone in men who are on testosterone therapy, making sure that estrogen levels remain stable. Estradiol readily converts to estrone and in some cases, estradiol may remain stable but there can be a marked elevation of estrone. A 24 hour urine collection also measures bioavailable hormones, including testosterone, DHEA, estrone, estriol, estradiol, pregnanediol, cortisol, and their metabolites. It is also an accurate and cost effective way to monitor hormones. Again, when testing blood a free testosterone is critical for making a diagnosis of androgen deficiency. Remember, ‘low normal’ and ‘age adjusted’ levels of testosterone are not adequate to prevent disease and maintain health. Thyroid function is also critical for health and is tested on blood.
16. Options for HRT in men include bioidentical testosterone, identical to the hormone found in the human body. Testosterone may be given as an oral capsule, a sublingual tablet or lozenge, or via the skin by a patch, gel or cream. It may also be given as an injection or implantable pellets. HRT for men may also include an oral DHEA capsule and a low dose progesterone cream. Other hormones like pregnenolone, cortisol, and thyroid are covered in the presentation ‘Hormone Balance and Health’ which is viewable on this website.
17. Oral testosterone is absorbed well from the gut but is metabolized and inactivated in the liver. Very small or ‘micronized’ particles of testosterone combined with oil are absorbed by the lymphatics and enter the systemic circulation via the thoracic duct to the subclavian vein, bypassing the liver. Absorption is variable, with some of the testosterone still entering the portal or liver circulation. Ester groups have been added to the testosterone molecule in an attempt to make testosterone more lipid soluble and enhance absorption through the lymphatics. Alkylated testosterones, like methyl testosterone are metabolized much more slowly, but as mentioned earlier, cause problems with lipid metabolism and liver toxicity. They should not be used.
18. Testosterone can also be delivered as a sublingual tablet or lozenge which is dissolved under the tongue or against the buccal mucosa. This avoids intestinal absorption and hepatic inactivation. The dose is usually 5-10mg used three times daily. Serum levels of testosterone peak rapidly, at about 30 minutes returning to baseline within 4-6 hours. One problem with the sublingual route is the elevation of both estradiol and DHT. There is a patented 30 mg buccal mucoadhesive system that is applied twice daily attempting to maintain more consistent levels of testosterone. Patients must avoid swallowing the saliva when using the sublingual lozenge or tablet, or the testosterone will be inactivated. Once again there is variability in absorption.
19. The Transdermal Delivery Systems or ‘Patches’ are patented products that have been around since the early 1990’s. ‘Testoderm’ is a patch which is applied to the scrotum and has been shown to have rapid absorption. Like the other testosterone patches it is applied daily. One of the problems with the scrotal patch, besides discomfort, is the elevated DHT levels which may result in the stimulation of the prostate gland. Other patented patches include Androderm and Andropatch which are applied to the skin of the abdomen. The 5mg patch delivers approximately 5 mg of testosterone daily, which is the average daily production of testosterone in healthy males. Patches are expensive and there is lack of dosing flexibility. The alcohol base, which enhances absorption, frequently causes skin irritation and or contact dermatitis. There can also be problems with hair and sweating. When compared to the percutaneous creams and gels, most men preferred the latter. Absorption is variable.
20. Testosterone can be applied to the skin as a cream or gel. This is referred to as percutanous application vs. Transdermal application, which refers to the patches. Different bases are used to deliver the testosterone. My preference is a ‘Natural Cream Base’ which does not contain chemicals that are often found in other bases. There is also a non irritating, non alcoholic gel and a hydro-alcoholic gel. The patented products like AndroGel, Testim, and Testogel are formulated with the hydro-alcoholic base. Compounding pharmacists can also compound with a hydro-alcoholic gel, which allows for rapid absorption. A 50-100 mg dose of testosterone cream or gel delivers 5-10 mg of testosterone, which is equivalent to the dose delivered by the Transdermal patches. You can combine a low dose of progesterone with the testosterone and apply it as a single cream. Depending on the concentration, 1-2 grams of cream or gel may be applied to the wrists, inner arms, abdomen, chest, and neck daily. It is best to rotate sites, rub vigorously, and wash hands if handling an infant. This method of delivery avoids inactivation by the liver and delivers a steady dose of testosterone throughout the day. However, there is variability in absorption with limited or no absorption in some thick skinned individuals.
21. Testosterone injections are widely used in Europe. They are cost effective and have consistent absorption. The intramuscular injections are well tolerated and effective. They can be useful in men who are mentally or physically handicapped. Adding an ester group to the 17 beta hydroxyl group of testosterone makes the testosterone fat soluble. The testosterone ester is hydrolyzed in the body releasing free testosterone. The long acting esters include testosterone cypionate which is usually given every two weeks. To avoid the peaks and troughs associated with injections, I have some patients on weekly injections at home. Testosterone Undecanoate is a longer acting ester which is being looked at as a method of birth control for males and may be able to be given at even longer intervals.
22. Testosterone pellets have been used since 1940. They are implanted in the subcutaneous tissue of the lower abdominal wall. It does require a minor surgical procedure under local anesthesia and takes about ten minutes. Three to six, 200 mg pellets provide a physiologic dose of testosterone for 4-6 months. Testosterone pellets are an effective form of therapy with complete bioavailability. There is no elevation of Dehydro-Testosterone or estradiol. There may be a transient accelerated release of testosterone for 1-2 days after insertion, which is comparable to the injection. However, this transient elevation occurs two to three times yearly vs. every two weeks with the injection. Minor complications such as pellet extrusion, minor bleeding, and infection are rare. The first time pellets are inserted; testosterone levels are monitored at one month then at month 4, 5, and 6 to make sure that levels remain therapeutic. Another form of testosterone may be used as a trial prior to insertion of the pellets to make sure there is no elevation of PSA revealing an undiagnosed prostate cancer. Pellets may also be removed if needed.
23. A specialized pharmacy called a ‘compounding pharmacy’ is able to provide customized therapies based on a health care providers prescription. They compound or make oral capsules, sublingual lozenges or tablets, and percutaneous creams and gels. Some compounding pharmacies also make testosterone pellets and injectable testosterone. Pharmaceutical companies also make testosterone gels, patches, and injectable testosterone esters. We work with the Medicine Shoppe compounding pharmacies in Colorado Springs, CO.
24. Dosing and delivery method should be based on a patient’s potential benefits, risks, and preferences. Each patient is an individual. No two people absorb, metabolize or excrete hormones the same. Some people do not absorb the creams and gels at all, no matter how high the dose. Others do not absorb the sublingual lozenges. A health care provider must be willing to work with and listen to the patient. Oral capsules are not recommended because of variable absorption and elevated estrogen levels. Yet, some men do fine on oral micronized testosterone in oil. The sublingual dose is between 5 and 10 mg. two to three times daily. Some men find this inconvenient. The testosterone patch is applied daily and depending on the dose, delivers either 5 or 10 mg of testosterone per day on average. Once again, the range is variable. A 50 – 100 mg dose of cream also delivers 5 to 10 mg of testosterone daily. I have seen doses as low as 20 mg. per day recommended. The dose for pellets is anywhere from 600 to 1200 mg every 4-7 months with 800 to 1000 mg (4-5) being an average dose. As mentioned previously there is consistent absorption. Four 200 mg pellets release approximately 5.2 mg of testosterone per day. A 200 mg dose of testosterone cypionate may be given every two weeks or a slightly lower dose given weekly at home.
25. The cost of HRT is variable with the patented products being more expensive. A patented testosterone gel costs about $235 /mo whereas a compounded gel is about $30 to $45 /month. Sublingual tablets and lozenges cost between $30 to $60 /month. The pellets average about $60 per month as do the biweekly injections.
26. Testosterone does not cause prostate cancer and may even help to prevent it. However, testosterone may stimulate an existing cancer. A PSA , preferably less than 2.6 and a digital rectal exam must be obtained prior to starting testosterone therapy. A follow up PSA is then obtained at 3, 6, and 12 month intervals following initiation of testosterone therapy. If the PSA goes above 4.0, a prostate biopsy is recommended. Follow up estradiol, estrone, free testosterone, and testosterone levels are obtained at 1-3 months to make sure that the patient is absorbing the testosterone and not converting it to estrogen. Testosterone Replacement Therapy can restore the prostate gland to normal size and may raise the PSA level slightly.
27. In conclusion, it’s all about balance. You have seen how important it is to keep estrogen and testosterone in balance. Each person is an individual. Diet and lifestyles differ as does the ability to absorb, metabolize, utilize, and excrete hormones and their metabolites. Some men continue to make healthy levels of testosterone into their 70’s & 80’s while others experience symptoms of Andropause as early as their mid thirties. Hormone levels must be tested, whether by saliva, urine, or blood. The evidence shows that replacing deficient testosterone with bioidentical testosterone prevents disease. Hopefully, insurance companies will realize the huge cost savings that optimal, balanced HRT can provide by preventing and reversing disease. It makes no sense financially that they are unwilling to pay for testing or bioidentical hormone therapy which are a fraction of the cost of prescription medication and disease care. The patient must be an educated, active participant. They need to realize that it takes effort on their part to optimize their health.
28. The Testosterone Syndrome and The Hormone Solution are both excellent books as is Adrenal Fatigue by James Wilson. The Miracle of Natural Hormones provides thorough coverage of multiple hormones including the adrenal and sex steroids, as well as thyroid and human growth hormones.