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Andropause
Andropause is a gradual decline in sex hormone levels over years resulting in physical and psychological change. Depression, impotence, decreased sex drive, loss of muscle tone or strength and lethargy. 5 million men or more in the U.S. are currently suspected of experiencing symptoms of low hormone levels. From age 30 to 80 hormone shifts begin resulting in pre-teen levels in older men. Free testosterone levels decline at a rate of 100 ng. /dl. per decade. Free testosterone declines faster than bound as Sex Hormone Binding Globulin (SHBG) becomes more prevalent. Free testosterone declines by about 2% per year after age 50. Total active testosterone is less than 2% of the total which is bound in albumin and SHBG.
Hypogonadism (andropause) is underdiagnosed because of difficulties in recognizing the symptoms in affected men. Physicians are also poorly trained in this area of “functional” health. Screening forms can help make the diagnosis as well as common symptoms which include:
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Decreased beard growth
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Physical changes in body shape (pear shape/feminized) or weight
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Onset of hot flashes (rare, frequently due to sudden drop in testosterone)
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Decreased body hair
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Mood changes (depressed more common)
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Cognitive decline
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Breast enlargement
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Decrease in testicular size
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Frailty (sense of being delicate)
Classification of andropause includes:
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Hypergonadotrophic hypogonadism (primary testicular failure)
a. Adequate LH (testosterone) and FSH (spermatogenesis)
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Hypogonadic hypogonadism (pituitary slow-down or failure)
Testes are the source of 95% of all testosterone in men. The incidence is 50/50 in women from adrenal glands and ovaries. The wide range of normal laboratory values do not discriminate the true functional needs of each individual male. The “alpha” male who is aggressive, athletic and driven may require higher levels of testosterone than others.
Hypothalamic control is mediated by estradiol as well as testosterone decreasing GNRH without initial problems with testosterone. Therefore low testosterone with normal LH and FSH may reflect high estradiol levels. Supplements and medications can influence hormone levels as well.
Laboratory evaluation should include total and free testosterone, estradiol and estrone, PSA, CBC and blood lipids. Serum (blood) and saliva can be used to assess levels. Debate over which is best is always quite spirited.
Enzyme systems including aromatase and 5-alpha-reductase inhibitors (proscar, propecia) affect levels of testosterone and may be useful in optimizing hormonal balance. Estrogen’s involvement is critical in balancing levels of active testosterone. Testosterone converts to estradiol and globulins to estradiol can stimulate SHBG production. The aromatase inhibition should be considered as a safe part of increasing healthy male hormone levels.
Estrogen increases because of enzyme systems (aromatase), liver function problems, zinc deficiency, obesity, drugs and alcohol and environmental estrogens (xenoestrogens). Estrogen dominance creates symptoms of enlarged prostate, urinary problems, low sex drive, impotence, depression, fatigue and obesity (positive feedback with increasing aromatase with increasing obesity).
Hormonal balancing should result in improving libido, erectile function, mood, strength, bone mass, prostate health and diminished cardiovascular risk. The reduced joy and fulfillment that comes with hormonal deficiency can be reversed to some extent in many men. Though testosterone is not the “fountain of youth” it can restore many of the healthy attitudes and physiologic characteristics associated with young men.
Prostate issues are always a concern during hormone replacement therapies. The PSA readings should be done at 3, 6 and 12 months and should also trigger a referral to a urologic specialist. This area is controversial and worthy of careful consideration at every step.
Is It Andropause?
Do the signs and symptoms indicate andropause or a different problem, its possible to clearly identify the role that testosterone plays in these symptoms? Hopefully, this question can be dispatched with clarity.
Fertility is not directly related to testosterone levels as FSH regulates sperm development and LH controls testosterone production. However, testosterone may have a supportive role in healthy reproductive capability beyond sexual performance issues.
Gradual partial androgen deficiency, (ADAM, PADAM) produces multiple symptoms that are non-specific including: decreased energy, sexual dysfunction, bone loss, lipid, cognitive and muscle activity. Some common conditions that mimic testosterone deficiency include:
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Anemia
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Clinical depression
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Hypothyroidism
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Chronic illnesses (diabetes, arthritis, fibromyalgia)
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Medication side effects
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Troubled relationships
AMS = Aging Male Symptom Score (Heineman et al)
There is a poor correlation between AMS and testosterone levels. Obesity (high body mass index) and insulin levels can complicate evaluation and treatment of hormonal imbalances. Low testosterone may produce symptoms but frequently are unaware of these gradual changes. Bioavailable testosterone is decreased in more than 50 % of men over the age of 55.
Physical signs of low testosterone include:
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Hair loss on face, axilla, groin
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Skin thinning
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Capillary dilation
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Testicular volume reduction
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Increased waist/hip ratio
ADAM Questionnaire:
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Do you have decreased libido?
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Do you have a lack of energy?
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Do you have decreased strength and/or endurance?
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Have you lost some height?
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Are you sad or grumpy?
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Have you noticed a decreased enjoyment of life?
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Are your erections less strong?
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Have you noticed reduced ability to play sports?
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Are you falling asleep after dinner?
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Has there been recent deterioration in your work performance?
Morley, J. University of St. Louis (question 1 and 7 most specific)
Bioavailable Testosterone
The testosterone available to bind with tissues is called the bioavailable component. The hormone that is bound to SHBG is not available for receptor binding on the cell membrane. This SHBG component increases with age and obesity. Saliva testosterone is good for screening but may be less valuable for treatment and monitoring. Though convenient it measures a “snapshot” and not the steady state of testosterone through the day. Lab normal values are based on an 8AM specimen and should be checked at that time.
Balancing Testosterone
The best approach to increasing testosterone level is transdermal bioidentical supplementation. Prohormones have some benefits but are less effective. Limiting the conversion of active testosterone to its downstream metabolites can be effective through the use of aromatase inhibitors like zinc and reductase blockers like saw palmetto.
Obesity In Men
BMI (Body Mass Index) that is greater than 30 kg/m2 indicates obesity by World Health Organization (WHO) standards. The waist hip ratio (WHR) > 1 indicates increased risk of diabetes, hypertension, hyperlipidemia and coronary artery disease. Obesity in middle age is highly predictive of death from obesity-related problems in older age. The best time to reduce body mass is now. Later may be too late.
Obesity can be related to these conditions:
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Hypertension
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Dyslipidemia
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Type 2 diabetes
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Coronary artery disease
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Stroke
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Gallbladder disease
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Osteoarthritis
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Sleep apnea and respiratory problems
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Breast, uterine, prostate and colon cancer
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Polycystic ovary syndrome
Metabolic Syndrome (NCEP definition) 3 of 5 factors:
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Abdominal obesity
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Elevated blood pressure
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Elevated fasting glucose
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Elevated triglycerides
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Low HDL-C
Treatment of the metabolic syndrome should begin with appropriate reduced calorie eating plan with a progressive exercise program. Frequently, behavioral interventions are helpful. Writing down every thing that is eaten will enhance self-control and understanding areas for improvement. Support groups and commercial weight-loss programs can be beneficial in this context. Without exercise it is uncommon to maintain weight loss success. After 6 months of diet and exercise it may be necessary to add medication or more aggressive supplementation to achieve continued reduction of risk factors. In life-threatening conditions surgery may be a consideration.
Testosterone levels are generally lower in overweight and obese patients. These relationships suggest a possible benefit in administration of testosterone to those with metabolic syndrome. With functional deficiency of testosterone this group of patients may show reversal of negative predictors and improvement in well-being. These patients should always be encouraged and supported in the diet and exercise programs on a long-term basis.
Nutritional Aspects of Wellness
Infertility and Nutrition
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Excess insulin production
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Excess inflammation
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Excess stress
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Excess sedentary lifestyle
Excess insulin and growth factors are produced in response to carbohydrate intake. Excess calories from any source can also create dysinsulinemia. Insulin activates metabolic pathways and is a storage hormone. Excess insulin can be thought of as a signal for “hibernation.” Nutrients to enhance carbohydrate metabolism include:
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B and D vitamins
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chromium, vanadium and zinc
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magnesium and calcium
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alpha-lipoic acid
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quercetin
A balanced low-glycemic load diet will produce dramatic impact on insulin production and metabolic activation. (Glycemic load is defined as the simple carbohydrate stress presented to the system as a factor of glycemic index and fiber content.)
Excess inflammation is a common consequence of high-glycemic load diets. Omega-6 oils are prevalent in the typical American diet. The ratio of Omega-3 (fish oil, cod liver oil) to Omega-6 oils should be 2:1. Typically this ratio is as low as 1:50. The addition of fish oil to the diet, at doses of 4-10 grams per day, can restore a healthy fatty acid ratio. Adding Omega-9 oils (olive, almond, avocado and macadamia nuts and oils) is also important in reducing inflammatory activity through the “fat pathway” of eicosanoids which send messages from cell to cell.
The end product of inflammatory activity is arachidonic acid. The end product of healthy fat metabolism is the “anti-inflammatory” fat, docosahexaenoic acid (DHA). This fat acts in many ways like cortisone-like drugs.
Excess stress stimulates increased cortisol levels which increases glucose levels and insulin levels. Cortisol irritates the hypothalamus and disrupts normal hormonal balance. Lack of sleep, nicotine and caffeine stimulate cortisol output.
Cortisol levels can be reduced by meditation, deep abdominal breathing, prayer and exercise. Sedentary lifestyle should be addressed by daily walking or other similar activities that boost the heart to a target rate for 30 to 60 minutes per day. The highest value exercise program is the one that is fun to do.
Treatment of Andropause
How can a healthy hormonal balance be achieved?
Through reducing estrogen, increasing production of testosterone and supplementing with hormone and nutrients optimal chemistry can be attained.
Estrogen Reduction mechanisms:
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Weight loss
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Moderate exercise
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Balanced diet
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Zinc supplements
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Aromatase inhibitors
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Chrysin
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Bioflavonoid/antioxidant
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Natural substance
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Increases free testosterone
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Topically 100-300 per day
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May reduce dosage need for testosterone
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Arimidex (very strong/too strong?)
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Commercially available
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½ to 1 mg three times weekly
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Progesterone
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5-alpha reductase inhibitor (weak)
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2-10 mg per day
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Saw Palmetto
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5-alpha reductase inhibition
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Anti-inflammatory
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Inhibits androgen binding
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Decreases smooth muscle contraction/epidermal growth factor
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160 mg twice daily
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Androstenedione
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4-androstenediol
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Immediate precursor to testosterone
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No direct estrone conversion
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60-100 mg topically daily
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Nettle Root
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Inhibits DHT binding to prostate
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Inhibits 5-alpha reductase
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Competes with testosterone for SHBG
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240 mg daily
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Diindolylmethane (DIM)
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Indole-3-carbinol is parent
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Shifts from cancerous to healthy estrone
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Competes with testosterone for SHBG
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50 mg topically daily
Testosterone Supplementation
Oral supplementation is a problem because of liver metabolism and side effects. Injection has higher side effects and variable response through the few weeks between administrations. Sublingual or buccal dosing gives rapid absorption but because of short half-life of testosterone requires frequent administration.
Twice daily topical administration is most physiologic with steady release and easy titration. Transdermal (topical) application does not elevate the PSA level.
Applied to non-fatty areas of shoulders, arms, thighs dosed from 50 to 200 mg twice daily. Blood levels should be done approximately 2 hours after dosing. Absolute values of laboratory studies are not closely correlated to symptom severity.
Nutrient Supplementation
Zinc, DHEA, Omega-3 oils, selenium and vitamin D and E, lycopene, saw palmetto and stinging nettle have all proven valuable and should be individualized to meet the goals of maximizing healthy hormone levels.
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