Download Andropause, Hormone Balance for Men

Andropause, Hormone Balance for Men
1. Hello, I’m Dr. Rebecca Glaser and I would like to welcome you to the slide
show presentation, ‘Andropause, Hormone Balance for Men.’ In this
presentation we will discuss the impact that declining testosterone levels have
on both mental and physical health.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
9. 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.
10. 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.
11. 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.
12. 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.
13. 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.
14. 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.
15. Hormone testing may be done using saliva, urine, or blood. More detailed
information can be found on this website under ‘Presentations’... ‘Hormone
Testing’. You can also find information on testing by clicking on ‘Hormone
Testing’ under ‘Featured Reference Sites’. It is important to measure
bioavailable or free testosterone when checking hormone levels. 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.
16. 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. Both saliva testing and 24 hour urine testing cost less than
$250.00. Blood testing can cost over $1000.00 when free testosterone and
free estradiol are included. 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. The cost for T4, free T3, and TSH can range from $85.00
(through LEF) to over $350 at a local laboratory. If human Growth Hormone
is going to be part of HRT an IGF-1 is measured and followed as a reflection
of HGH.
17. 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.
18. 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.
19. 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.
20. 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.
21. 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 510 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.
22. 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.
23. 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.
24. 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. To
find a compounding pharmacy, on this website, go to ‘Topics’ …compounding
pharmacies or ‘Featured Reference Sites’…Find a compounding pharmacy.
25. 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.
26. 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.
27. 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.
28. 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.
29. Life extensions foundation has an excellent article on their website called
‘Male hormone modulation therapy’ which can be linked to from this website.
Go to Links…Links for men… and click on the testosterone protocol.
www.salivatest.com offers information on hormone testing and Andropause.
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.
30. Thank you for visiting www.hormonebalance.org. I hope you enjoyed the
presentation.