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Saturday, 26 July 2014

Testosterone, aka The Fountain of Youth

By Adam Swenson

Let’s do a quick mental exercise. Imagine a young man in tip-top health. Physically, emotionally, and mentally he is at his best. He could be out playing sports, at work, or reading a book. What characteristics does this man have?

Odds are the man you pictured is strong, lean and athletic, has abundant energy, is generally upbeat and optimistic, and has a sharp mind and a good memory.

This, in broad strokes at any rate, is what most men aspire to. This state of being, men feel, will allow them to enjoy all life has to offer and feel good about themselves.

Now imagine this young man 20 years older. He may be a little weaker, a little less taut in the midsection, a little slower, maybe more docile, moody, not as quick mentally, and he loses things. A decade further down the line, the picture worsens for our poor example man.

Has this man replaced carrots with Cheetos, running marathons with movie marathons? If so, lifestyle adjustments may be able to bring back some of the lost luster. But some men do everything right and just can’t get their mojo back.

The answer lies in the quintessential male hormone: testosterone. Many American men have low testosterone (low T), some critically low. This manifests itself as unexplained fatigue, depression, or lethargy; erectile dysfunction or obvious loss of libido; diminished strength and physical stamina. Sound familiar?

And The Survey Says…

A recent study of low-T men (average age of 57) broke them into four groups, monitoring body composition for one year. The first group served as a control—they had no intervention. The second group did testosterone replacement therapy (TRT) and worked under a nutritionist and a trainer. The third group did only TRT, and the fourth group only worked with a nutritionist and trainer.

Somewhat predictably, those that did nothing gained body fat, and those who had TRT and worked with the trainer lost the most weight. The surprising finding, however, was that those who only received TRT had more positive changes in body composition than those that did only the lifestyle changes.

In another study, a group of men receiving long-term TRT lost an average of 36 pounds over a two-year period. And perhaps this shouldn’t be that surprising. Alan Christianson, NMD, is a hormone balance specialist and the founder of Integrative Health in Scottsdale, AZ. But before he had any letters behind his name, he spent his childhood on a farm in northern Minnesota where he got perhaps an uncomfortably close look at the link between low testosterone and fat. “Growing up on a farm, we wanted our pigs to be as heavy as possible by the time they got to market,” he said. “The first thing we would do is we would castrate them.”

Low Testosterone by the Numbers

A 1996 study checked an average of 175 non-diabetic men in five-year age groupings (25-29, 50-54, etc). It found that mean total testosterone in men under 25 was 692 ng/DL, whereas men aged 55-59 averaged 552. Another study tracked men all the way up to 85-100—their mean total level was 376.

Christianson says a borderline number for low testosterone is 450—below that the picture becomes clearer. “There is a state at which testosterone being low is actually a medical risk. It actually raises the risk of total mortality, cardiovascular mortality, and diabetes. That is somewhere around 250. Sometimes if men are deficient by a small amount, you can work with what they have and coax it out, but when men are as low as 250 and below, even if they don’t have symptoms, it is medically appropriate to treat the same way you would treat for high blood pressure or high cholesterol. It is just an unhealthy physical state that they are in at that point.”

A recent study showed that 2.4 million American men ages 40 to 69 suffered from hypogonadism. Christianson says, “Hormones you think about as being on a continuum, and hypogonadism is where your testicles have pretty much failed: those are by far the most severe cases. As you look at those that haven’t had testicular failure but aren’t making optimal amounts of hormone, it ends up being a substantial amount of the aging population.”

You can discover your testosterone level through a simple blood test—that is considered the most accurate. Salivary and urine tests are relative newcomers and are certainly less invasive, though they are often not as accurate. Christianson tested himself with blood, saliva, and urine tests within a two day window. The saliva and urine tests gave completely different readings. On top of that, the blood test is the one most commonly covered by insurance, so it makes for a clear plan A.

(The other tests do have their strong suits: urine tests are helpful in showing a large number of hormones and giving doctors insight into how the conversion and breakdown process is occurring in that particular patient. The salivary tests are very good for testing cortisol as that has to be tested at multiple points throughout the day.)

The Culprits: Natural and Pharmacological

Low T can have a variety of causes. As men age, production will drop off naturally. (As referenced earlier, the under-25 set averaged 692, while the over-85 set averaged 376—a 46 percent drop.) In hypogonadism, the testes fail and testosterone plummets. Lifestyle factors, namely inactivity and the accompanying excess fat, can certainly play a role. A 2010 study of 2,165 men age 45 and up found that 40 percent of obese participants had lower-than-normal T readings. Among obese men with diabetes, that level rose to 50 percent. Testosterone decreased markedly as BMI rose. Also, men with diabetes—obese or not—showed lower T levels than their non-diabetic counterparts.

To further obfuscate the issue, there are a wide variety of medications that either play an active role in lowering testosterone or have side effects that mimic low T levels. Statins (cholesterol-lowering medications) have a clear effect. “Cholesterol is actually the backbone for testosterone,” says Christianson. “Biochemically, steroid means every hormone of cholesterol. Kind of a simple rule of thumb is hormones that come from below our waist—so from ovaries, from testicles, or from the adrenal gland—are all steroids. They are all just slightly repurposed cholesterol molecules. If we are not synthesizing cholesterol the way our bodies want to, that can alter how we form our steroids and how we form certain hormones. That is the cholesterol tie-in.”

There are other medications that will mimic the effects of low T, even though they have no effect on T itself. Blood pressure medications can affect the erectile function. Selective serotonin reuptake inhibitor (SSRI) meds impact some of the brain steroids related to cholesterol that give us the psychological sex drive. Analgesics and antihistamines are sedating and can therefore diminish energy and exercise capacity, two hallmark symptoms of low T.

One other factor to consider: a naturopathic doctor might spend a little more time with a patient before diagnosing them with low T and writing a script. “Some men are simply carrying a big burden of cadmium or lead in their bodies and some may have issues with not properly breaking down precursor hormones by their liver,” he said. “Some may have nutritional things that they are lacking. We do screen pretty thoroughly and there are times where—especially in men that may be low before we would expect based on their age, or low by a smaller amount—there can be factors short of replacement therapy that can correct them.”

The Manifestations of Low T

Metabolic syndrome (also known as the somewhat more catchy “diabesity”) is getting a lot of press right now, and appropriately so. According to recent Center for Disease Control (CDC) findings, 33.8 percent of Americans are obese. Low T plays a key role in metabolic resistance and the consequent greater production of insulin. “Think of it as a seesaw: on one side is testosterone, and on the other side is insulin. When the testosterone gets lower in the body, we have a hard time managing our blood sugar, and we have to make more and more insulin to process the same amount of carbohydrate. The more insulin we make, the more we store our calories and the less effectively we burn calories,” Christianson says.

A recent study published in Endocrine Journal said, “Testosterone has neurobehavioral, somatic, and metabolic effects in adult men. Patients with hypogonadism not only have loss of libido and erectile dysfunction, but also have several other problems such as fatigue, increased body fat, osteoporosis, mild anemia, gynecomastia [enlarged breasts], sleep disturbances, and hair and skin changes.” With typical academic understatement, the study goes on to say, “All of these conditions may cause anxiety and depression in these patients.”

Treatment Options and Guidelines

The goal with TRT is to restore someone with low T to the level that would be typical for a healthy male in his mid-30s: about 600 to 850. In a critically low patient (250 or under) that can mean tripling his levels. “The idea is that you want to give the lowest dose that will bring someone back to that level. If the dose you’re giving takes someone way above the body’s normal level, then it’s just not what our chemistry is adapted to and also it will depress your own output. If you bring someone back to normal ranges, but not well above that, there is no substantial suppression on what their own output is.”

That is a very relevant point. Very high doses of testosterone can lead to bad hormone byproducts and shrinking of the testicles—best not to go there. And since unnaturally high doses suppress the body’s natural ability to produce testosterone (bodily production is no longer needed), this patient would dip to perilously low levels should he lose access to the medication. Proper dosing prevents those risk factors that people sometimes associate with testosterone supplementation.

And, as you might suspect, testosterone is not all created equal. Christianson advocates bioidentical hormone replacement therapy (BHRT), meaning that the hormones are in the same molecular configuration as the T made by the body—hence the term bioidentical.

“There are a lot of molecules out there that do things kind of like testosterone can do but aren’t really testosterone,” he says. “Those were used in the past for replacement therapy or more so [currently] for steroid abuse purposes. Using the same molecule your body is engineered for really makes it work the smoothest. It is just like running your car on gasoline rather than kerosene.”

Interestingly, bioidentical hormones are sourced from plant hormones—there are a variety of plants that make precursors to cholesterol called dioxygens. These can be turned into testosterone, estrogen, or progesterone.

Testosterone can be administered orally, topically, or via injection, though injection is the best of the three. Pills have fallen out of favor because they must first go through the liver, where hormones can get broken down in undesirable ways. Topical applications face a similar problem as skin enzymes convert hormones as well.

“When men who are very, very obese develop breast tissue, it is because fat tissue converts testosterone into estrogen. When testosterone comes into the body by crossing the skin, there is more of a chance of it being converted that way,” Christianson says. This would, obviously, be counterproductive.

Shots enter the bloodstream directly from muscle tissue and best approximate the body’s own production—they are thus the delivery method of choice. There is a long-lasting supplement administered via subdermal shot that Christianson particularly likes. It’s about the size of a grain of rice and lasts about three months.

Outcomes (Desired and Otherwise)

The aforementioned study in Endocrine Journal had this to say regarding the outcomes from TRT. “TRT restores normal sexual functions and improves libido, fatigue, sense of well-being, bone density, muscle mass, body composition, mood status, and cognition. Overall, the restoration of the above parameters is expected to improve the quality of life.” Again, a fair assumption. TRT has been linked to various health problems in the past, mostly due to improperly high dosing or hormones that were not bioidentical. Prostate cancer was at one point linked to TRT, though that has been definitively cleared. TRT is a culprit for prostate enlargement, the more benign type that causes frequent urination.

As far as desired outcomes go, if a man goes from 275 to 650 on the scale, Christianson says, “There is a very, very strong positive correlation to healthy libido.” The psychological aspect improves pretty quickly (two to eight weeks) but the physiological side sometimes takes a little longer. “Most men have seen a good [physiological] change within four to six months, but there are some where it does take a full year.”

Memory and concentration have also been shown to improve with TRT. “There are a variety of compounds that the brain makes that we are learning a lot about lately called neurosteroids. Basically, they’re neurotransmitters that are products of testosterone. Many papers have shown now that low testosterone is a big factor in triggering early Alzheimer’s disease and also non-Alzheimer’s age-related dementia … It seems that a certain amount of our memory is tied into a healthy, normal amount of assertiveness or aggression. If we have an extreme excess of these neurosteroids, we are inappropriately aggressive. If we have a deficit, there is a connection between being apathetic and not having healthy drive and not having good memory for events or good spatial memory: where are you at or how do you get home, things like that.”

A Return to Form

Consider our conceptual young man in tip-top health. As men age, many resign themselves to less-than-ideal body composition, sexual function, mood, memory, and mental acuity, but that need not be the case.

As the great poet Dylan Thomas wrote, “Do not go gentle into that good night, Old age should burn and rave at close of day; Rage, rage against the dying of the light.”

Low T: It’s Not Just an Old Boys’ Club

Testosterone also plays a vitally important role in women. In general the ratio of testosterone found in men and women is about 10 to 1, and low T in women manifests itself with many of the same symptoms: libido, lethargy, depression, and so on.

“By their mid-40s, I would argue that probably 80 percent of women are below optimal in testosterone nowadays,” Christianson says. “Somewhere around 40 to 90 is the healthiest range for women and many are below that—some in the single digit range. They can just see phenomenally good changes to their health and their life when that is corrected.”

The North American Menopause Society’s statement on the issue says that “Published evidence from randomized controlled trials, although limited, indicates that exogenous testosterone, both oral and nonoral formulations, has a positive effect on sexual function, primarily desire, arousal, and orgasmic response, in women after spontaneous or surgically induced menopause.”

They caution against TRT without concomitant estrogen therapy and also state that doctors must be careful to rule out causes not related to T levels—then be sure there’s no physiological cause for reduced T levels—before prescribing.

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