By Dr. Emilia Ripoll, M.D.
“Testosterone is more than a ‘male sex hormone.’ It is an important contributor to the robust metabolic functioning of multiple bodily systems.”
— Dr. Jerald Bain M.D., endocrinologist
If you watch television, you’ve undoubtedly seen one of those Viagra commercials that show men doing manly things that usually involve classic cars or large pickup trucks. The overtly masculine voice-over informs us, “This is the age of taking action.”
Even though I think those ads are silly, I agree with their message, but not because I think every man with a little gray in his beard should be taking Viagra. If you’ve reached a “certain age,” you do have more wisdom and experience to fix what isn’t working in your life — or at least you know where to go to ask the right questions.
Another popular TV ad shows a man in his 40s talking about how his doctor told him that he had “Low T,” which sounds more like the name of a hip-hop artist than a medical condition. These ads are closer to the truth because they mention that falling testosterone levels can affect memory, mood, vitality, sex drive, erections, and a man’s overall zest for life. I also like the fact that younger men are talking about hormone optimization because the need for it is becoming more common among that age demographic.
Obviously, there’s a lot more to declining male sex hormone levels than appear on TV commercials.
Andropause (sometimes called “male menopause”) is similar to the menopause women experience; however, the decline in male sex hormone production is so gradual that most men don’t realize it’s happening until they wake up one day in an asexual fog where everything feels “out of sorts,” they can’t find their car keys, and they’re torqued off about it.
Andropause affects all men if they live long enough. Free testosterone levels decline approximately 10 percent per decade (one percent per year) after a man turns 30. In addition, sex hormone binding globulin (SHBG) production increases after 40, so more of a man’s testosterone is bound (unavailable) to perform its normal function in the body.
While a man’s testosterone levels are declining, his estrogen levels are either holding steady or increasing. (Yes, men have estrogen in their bodies.) The net effect of both these hormonal changes is a lowering of the testosterone/estrogen ratio, which has all kinds of unwanted physiological, psychological, and emotion repercussions: poor memory, fatigue, insomnia, lack of stamina, loss of muscle mass and bone density, diminished sex drive, erectile dysfunction, mood swings, depression — even an increased risk for prostate cancer. After all, testosterone is what makes a man “a man.”
In my practice, I see a surprising number of younger men for hormone replacement therapy who do not fit the classic profile for andropause patients — men in their 50s, 60s, and 70s who are displaying symptoms of being past their prime. For example, I recently treated a man in his mid-30s who had a testosterone level of 500 and an estrogen level of 450. No wonder he was struggling with weight gain, mental fatigue, concentration issues, and the feeling that life had become increasingly gray. Fortunately, he is young enough that he hadn’t begun to develop sexual symptoms yet.
“The primary hallmark of low testosterone is low sexual desire or libido, but another can be erectile dysfunction, and any man who complains of erectile dysfunction should get his testosterone level checked,” states Dr. Abraham Morgentaler, M.D., an associate professor of surgery at the Harvard Medical School and director of Men’s Health Boston.
The goal of treating andropause is to return a man’s sex hormone levels to what they were previously. This is where your doctor’s skill comes into play because most men do not have testosterone baseline numbers from 5, 10, 15, or 20 years ago. This lack of information is why a complete physical (with blood work) and medical history are so important. In addition, no two men have the same biochemistry, so every man responds differently to hormone replacement therapy.
For example, two men of roughly the same age, general level of health, and testosterone levels may require a different dosage of male sex hormones — and sometimes additional hormones like DHEA and DHT or estrogen blockers— to diminish their andropause symptoms and create a new sense of ease and vitality in their lives.
One of the most common mistakes in treating andropause is looking at testosterone in isolation and not taking into account all the organ systems, particularly the endocrine system. This is where an intricate knowledge of the biochemistry of hormone supplementation becomes critical to the patient’s success. When I evaluate men for andropause therapy, I always check the following:
- Any evidence of prostate cancer (digital rectal exam, PSA, and other tests)
- Sex Hormone Binding Globulin levels
- Testosterone/Estrogen ratios
- The roles that DHT and estrogen play in this hormonal dance
- Levels of other (non-sexual) hormones that may indicate a man’s endocrine system needs more of an overall jump start
- Androgen receptor polymorphism
Because of the body’s interconnected complexity and wisdom, integrating all these factors into a comprehensive treatment plan is neither simple nor straight forward; however, seeing the smiles on my patients’ faces when I ask them “How are you doing?” is worth all the time and effort.
So yes, the Viagra people have it right: This is the age of taking action — smart, skillful action that is tailored to meet each patient’s specific needs.