Hormone Replacement Therapy for Men

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Did you know that a man’s testosterone level peaks at about age 25 and begins a long steady decline until death? By the age of 55, a full 30 percent of men have testosterone levels that are considered inadequate. By 70, this percentage climbs to nearly 50%.

And testosterone isn’t alone in this slow downward decline of hormones. Growth hormone, thyroid hormone, cortisol and other hormones all slowly decline as we age. Balanced replacement of these and other hormones can lead to increased vigor, decreased fatigue, and increased mental acuity.

Some of the conditions that are affected by hormone loss are listed below.

1. Andropause: The Slow Fade

The term andropause has always bothered me.

Andropause is supposedly the male equivalent to menopause. Instead of losing estrogen, men lose their vitally important testosterone as they age. Testosterone is literally what makes a man a man. There are rare cases where a male fetus cannot make its own testosterone due to a genetic mutation. When these babies are born, they appear female in all outward respects (they actually do have testes - in the abdomen). Conversely, a female fetus bathed in too much testosterone will look like a male (external equipment and all - no testes though).

Rising testosterone levels at adolescence causes the growth of facial hair and pubic hair, deepens the voice, enhance muscle development, and furthers the development of the secondary sexual characteristics. In other words, turns the boy into a man.

Testosterone levels continue to rise until the mid-twenties and then a slow, inexorable decline occurs over decades to the point where at age 90, it is not uncommon to see levels that are a fifth of the level seen in healthy 25 year olds. When testosterone levels decline to a certain point (and this varies from man to man), the extremes of andropause are expressed.

But andropause is not a distinct event and there is no clear physiological sign that defines pre- and post-andropause. This is not the case in menopause where a pre-menopausal woman has periods and is fertile and post-menopausal woman doesn't have periods and is infertile (the transition is not so clear in menopause either and it cantake years. But even so, for every woman there comes that last period. Six months after which a woman earns the label "post-menopausal").

So, andropause is not a "pause" at all. It is more like a slow fade. Turning the volume down REALLY slowly over decades. So slowly that day-to-day, month-to-month, and even year-to-year, the change is almost imperceptible. But what is happening in the body? A slow loss of muscle (often accompanied by more abdominal fat), the voice gets higher, depression sets in, the brain slows, and, the scariest thing - the erection goes away (okay, I am man after all).

What is this most reliable indicator of clinical significant decline in testosterone? The loss of the early morning erection. I can almost always predict which of my clients have low testosterone by the absence of "early morning wood". Other clues are loss of muscle mass, higher voice, abdominal fat, lack of interest in sex, depression, fatigue, "brain fog", erectile dysfunction, gynecomastia ("man boobs") and lack of a healthy glow.

With appropriate lab tests and any of the symptoms above, a diagnosis of low testosterone can be made and appropriatetreatment can be started.

The amazing thing is that most symptoms of "low T" can be reversed (at least partially) with testosterone supplementation. Erections can be restored, depression can be lifted, energy comes back, muscle mass can be restored with appropriate exercise. Testosterone supplementation can be truly transformational in some men. And all that was done was restore them to the levels that they had in their mid- twenties.

2. Hypothyroidism

Facts about hypothyroidism:

  • It is the most common hormone deficiency in adult Americans
  • About five percent of adults have some degree of thyroid insufficiency
  • Hypothyroidism remains under-diagnosed and under-treated by mainstream physicians 
  • There are constantly changing guidelines for diagnosis and treatment of low thyroid states
  • Physicians often misinterpret laboratory tests for thyroid disorders ("Your thyroid is normal") 
  • Hypothyroidism is one of the easiest hormone deficiencies to identify and treat

The top ten signs and symptoms of low thyroid are:

  • fatigue
  • cold intolerance
  • weight gain
  • constipation
  • myalgia
  • menstrual irregularities
  • slow movement and slow speech
  • skin changes
  • hair changes and hair loss
  • cognitive impairment

Thyroid insufficiency can span a range from a mild deficiency that is only evident when the body is stressed to a near complete lack of thyroid hormone which results in all of the above (and more). Thyroid hormone is a "major" hormones ("major" meaning necessary for life). The "big three" major hormones, cortisol, thyroid, and insulin, play central roles in the regulation of metabolism and growth. Without them, we cannot survive for long.

Fortunately, we have good simple tests to assess thyroid gland function. Unfortunately, most physicians order only one (TSH) and often under-interpret TSH levels. Using the appropriate tests and assessing symptoms in relation to lab results can help most patients achieve the proper balance of this vitally important hormone.


3. Low libido

"Honey, if you were awake, I would have a headache."

After food and survival, sex has be third most important human drive. Without sex and its intended (or unintended) consequence of pregnancy, the species cannot survive. Why then is lack of libido (low sex drive, lack of interest in sex) so common?

There are many causes of lack of libido. Some of the more common include:

  1. Medications
  2. Psychological conditions
  3. Hormone imbalances
  4. Sedentary lifestyle
  5. Concurrent illness
  6. Alcohol
  7. Recreational drugs

Many prescription drugs can affect libido. The prime offender among these is probably antidepressants of the SSRI class. Even while depression can cause low libido, some of the most effective treatments for depression can, strangely enough, cause it as well. This is a common situation which requires a careful managementto balance effective antidepressant therapy and control of this well-known side affect.

Other common prescription medications that can cause low libido are: beta-blockers, benzodiazepines, narcotic pain medications, statins, blood pressure medications, medications for BPH, and others.

The list of psychological conditions that result in low libido is lengthy. Special note should made of depression as low libido so commonly associated that it is one of the diagnostic criteria for depression.

Low testosterone and low estrogen in BOTH men and women can cause low libido. A proper balance must be maintained to have a healthy sexual drive. Other hormone imbalances that are associated with are hypothyroidism and adrenal fatigue.

Alcohol and recreational drugs (particularly opiates and marijuana) can depress libido both through their direct effects on the brain and through the indirect effect of depressing testosterone.

Other illnesses can depress libido not only by affecting hormone balances, but also through the release of substances that cause fatigue.

By properly balancing hormones, addressing underlying issues and understanding care low libido can effectively be treated in almost all cases.


4. Weight gain: why can't I lose weight?

You hear it all time.

"I used to be able to eat like a horse and not put on a pound"

"If I so much as look at a piece of cake, I put on weight"

"I go to the gym every day and can't lose a pound."

What is it about growing older (not growing old) that changes our ability to keep off the pounds? If you were like me as a teenager, a double-double burger, fries, and a shake would melt off like a snowball in the desert sun. Now the shake and fries are long gone and half the bread on the burger is given to Chloe, my golden retriever.

There are a multitude of factors that make us fatter and keep us fatter. Genetic, hormonal, environmental, and cultural influences can all conspire to keep the adipocytes (fat cells) nice and plump.

Here are a few of the major causes:

1. Resting metabolic rate goes down with age.

Resting metabolic rate (RMR) is the energy expenditure your body uses for maintenance (it is basically the calories that you are burning when not moving and not digesting). RMR decreases slowly with age to the point where a 60 year old may have a RMR that is 75% of a twenty year old. This translates to nearly 300 calories a day. That is, the twenty year old can burn a lot more calories just standing or laying around laying down. To me, that is 60 minutes on the treadmill. Every day.

2. You are female.

The gender differences between men and women conspire to make it more difficult for women to lose weight. Women tend to store more fat in butt, hips, and thighs while men tend to store it around the midsection. Upon vigorous exercise, abdominal fat is preferentially recruited for burning, making fat loss in those "problem areas" difficult.

In addition, women have less muscle mass than men. Muscle being more metabolically active burns more resting calories and more calories during activity. Therefore, men can burn more calories just being a couch potato.

3. You are eating the wrong foods.

I won't even begin to go into efficacy of different diets, however, a few basic guidelines can be agreed upon by just about anyone in the nutrition field. That said, much of diet lore is simply myth and has no scientific basis.

In any diet you should:

- eat protein at every meal (protein helps build/maintain muscle which causes more calories to be burned)

- take good quality supplements to help your metabolism

4. You can't lose weight by dieting alone

Recent studies have confirmed what has been suspected for many years. Both diet AND increased exercise are necessary to lose weight. Neither alone helps you lose weight. You may have put on the extra pounds by overeating and under-exercising, so is it really surprising that you need both dieting and increasing exercise to lose weight?

5.  You may not be sleeping enough

Here is some good news. A good night's sleep helps burn calories. A good, uninterrupted 7-9 hrs a night is needed for this benefit.

6.  You may be sleeping too much

However, sleeping too much can result in excess weight gain. Though the mechanism is unclear, more than nine hours of sleep is associated with weight gain.  Again, the sweet spot is 7-9 hours of uninterrupted sleep.

7. Your hormones are out of balance

All the major hormones (and some of the minor ones) can affect weight. The big three, thyroid, cortisol, and insulin, must be in balance to maintain a lean body.

8. You have an unrecognized food sensitivity

Food allergies and sensitivities can contribute to weight gain by altering the permeability of the gut.

9. You may have the wrong genes.

There is clearly a genetic component to excess weight. Very rare mutations can result in massive obesity and more common ones can lead to a propensity to excess weight. Many of these "fat genes" can now be identified by commercially available genetic testing.

10. You are getting bad advice about weight loss.

A balanced approach to weight loss can lead to long-lasting results. It doesn't need to be years of torture. Identifying and correcting misconceptions about diet and exercise are just a start. Adding food choice, hormone optimization, and pharmacological support can help the pounds disappear for good.