Male Andropause Part 1

The Diagnosis and Treatment of Male Andropause in Your Practice – Part I

by Dr. Greg Fors, DC – Board Certified Neurologist DIBCN Posted On: 08/11/2011

As your male patients pass the age of 40 they begin experiencing hormonal changes that inhibit their physical, sexual, and cognitive function. This process begins to accelerate after the age of 50 as notable symptoms can begin to manifest. The outward symptoms that are typical involve increased abdominal fat and decreased muscle mass, the hallmark of male hormone balance. Other common symptoms include depression, mental fogginess, difficulty concentrating, anxiety, decreased facial and leg hair, and a general feeling of not caring about anything. Until recently, these changes in your male patients were greeted with a slap on the back and a statement that, ‘they were simply growing older and not to worry’. This left the patient facing a hormonal imbalance, thereby causing a slow degenerative process eventually resulting in premature death.

Recent research has amassed a great amount of data that now indicates that many of the diseases the aging male experiences, including abdominal weight gain, a loss of energy and libido, depression, hypertension, prostate and heart disease are directly related to hormonal imbalances. Research is also showing that proper nutraceutical intervention can correct these hormonal imbalances and reduce the occurrences of these health problems. To our patients’ detriment, conventional doctors are increasingly prescribing multiple drugs to treat the depression, elevated cholesterol, hypertension and many other diseases that may be caused by this underlying hormonal imbalance. Further, it is made worse for the middle-aged male patient by the fact that very few doctors know which hormonal blood test to order, how to interpret them, and which nutraceutical approach to take in order to reverse observed imbalances. This comprises the primary subject matter of this article.

The Critical Importance of Free Testosterone It is only the testosterone not bound by proteins, called free testosterone that is bioavailable to bind to cell receptors and can stimulate cell function. As important as this free testosterone is to sexual function, free testosterone is much more than a sex hormone. Receptor sites in cells for free testosterone are found throughout the body, most notably in the brain and heart. Free testosterone stimulates protein synthesis, for example, in maintaining muscle mass and bone formation. Free testosterone also assists in controlling blood glucose levels, cholesterol regulation, optimizing cardiac output, improving tissue oxygenation and in the maintenance of immune system surveillance. Recently, multiple studies have shown that men who suffer with depression have lower levels of free testosterone than control subjects. Many of these studies have gone on to show that elevating free testosterone levels can be an effective antidepressant therapy.

Too Much Estrogen The primary hormonal imbalance in the aging male is not just decreased free testosterone available to the cells, but also a relative or absolute increase in estrogens. Small amounts of estrogen are necessary to turn off the powerful cell stimulating effects of testosterone. However, as estrogen levels increase with age they block free testosterone’s ability to stimulate cells, which leads to decreased libido, arousal and function. One of the primary mechanisms that cause excess estrogen in the aging male is the action of an enzyme called aromatase. This enzyme, which is primarily found in abdominal fat, converts available testosterone into estrogen. A primary cause of increased intra-abdominal fat deposition in the male is decreased levels of testosterone. Increased abdominal fat amplifies aromatase activity, further depleting available testosterone by converting it into ever higher levels of estrogen and thus creating a feed forward cycle.

Furthermore, as serum estrogen levels rise they can saturate testosterone receptors in the hypothalamic region of the brain. This causes the hypothalamus to stop stimulating the pituitary gland to release luteinizing hormone (LH), which is required by the testes for testosterone production. Another complication of excess estrogen is that it increases the production of sex hormone binding globulin (SHBG). SHBG binds to free testosterone in the blood, making it unavailable to cell receptor sites. To summarize, additional aromatase activity increases the estrogen levels in the aging male and tricks the brain into producing less testosterone. This along with decreased free testosterone levels through increased SHGB forms a vicious feed forward cycle.

A testosterone to estrogen imbalance is directly related to the degenerative health problems associated with the normal aging process in men. This imbalance of estrogen to free testosterone has been shown to increase the risk of heart attack, benign prostatic hypertrophy along with erectile dysfunction. Research has shown that the inhibition of the aromatase enzyme does result in a significant decline in estrogen levels while often increasing free testosterone to youthful levels. Therefore, aromatase inhibition and the lowering of available estrogen is a primary goal in any Andropause therapy program.

Diagnostic Lab in Andropause The most important laboratory measurements for your aging male patients are total testosterone, free testosterone and estradiol level. There is no reason you shouldn’t be able to gather this vital lab information on your patients. As the treating doctor, if you do not have an account through Quest Diagnostics, Lab Corp, Doctors Choice or Professional Co-Op, most states will allow your patients to order these tests themselves through an on-line service and report to a draw station near their home.

The “normal” lab range for male total testosterone levels is usually around 250 -1100 ng/dl, which corresponds to about 8.8 – 36.7 nmol/l. However, most aging males will notice symptoms when their total testosterone falls under 400 ng/dl, and males under the age of 40 will generally struggle with the total testosterone levels less than 500 ng/dl. In a study of 4,393 men between ages 20 and 44, average testosterone levels observed at 8 AM consisted of 679 ng/dl. Those young males with testosterone levels above 800 ng/dl were 40% less likely to experience high blood pressure and 70% less likely to have a heart attack than those with total testosterone levels of less than 400 ng/dl.(1) Though you cannot base diagnoses on just one lab reading, stress, a lack of sleep and many other lifestyle factors can decrease total testosterone by as much as 20 to 40%. Make sure your patients have their blood drawn in the early morning when male testosterone levels peak since levels can decline until late evening by as much as 50%. My optimal total testosterone level for men is between 500 ng/dl to 827 ng/dl.

Again, as males age not only does total testosterone levels go down but SHBG correspondingly increases. It is only the free testosterone that does your male patients any good. As such, 99% to 97% of total testosterone is bound up by SHBG and is no longer bioavailable. You should always order a free testosterone measurement along with that of total testosterone. Generally, the lab will provide you with free testosterone as a percentage of total testosterone; the typical lab range is usually listed at about 1.5% to 2.9%. I like my patients to be between 2% and 3% free testosterone. Direct free testosterone measurement is more ideal than percentage results. If your patient’s total testosterone and/or free testosterone is low there are specific nutraceuticals you can utilize to normalize these levels naturally, the subject matter of part two of this topic.

From our earlier discussion, remember that elevated estrogen levels are as big a problem as decreased testosterone in the aging male. With increased abdominal fat causing enhanced aromatase activity, estrogen levels will climb, which tricks the brain into producing even less testosterone and creating a feed forward cycle. Therefore, it is vital to get an estradiol level along with a total and free testosterone level measurement in your male patients. Normal lab values for estradiol are around 13 to 54 pg/ml; however, optimal estradiol levels for men should run between 10 to 30 pg/ml. Effective treatment options to balance the free testosterone to estradiol ratio will be discussed in detail in part two of this topic.

Multiple studies have shown that the decline in testosterone levels in males is an escalating problem for society. A 2007 study found that the average testosterone levels in men aged 65 and 69 had fallen to 423 ng/dl in 2003 down from the average of 503 ng/dl in 1988.2 This phenomenon is taking place within our modern lifestyles not only because of drastic dietary changes, but also because of increased exposure to chemical excitotoxins and pesticides in our environment, leading to oxidative stress and mitochondrial dysfunction. For a more in-depth exploration of this vital subject matter please see the book and website called ‘Our Stolen Future’ by Dr.Theo Colborn.

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  1. J of Behavioral Med, 1999, 22(1):1-19.
  2. J of Clin Endocrinology Metabolism, 2007, 92(1):196-202.