UNDERSTANDING MALE MENOPAUSE & ED
– by Dr David Saul M.D.
Mr. I. A. was my very first case of ED (erectile dysfunction), and it was because of him that I began to research male sexual dysfunctions and subsequently developed my interest in men’s health and the treatment of ED. Mr. I. A, was 47 years old and his initial complaint was a lack of sex drive. Medically speaking, this is termed as “loss of libido.”
“I just lost my interest in sex. I could do without it, if you know what I mean. Fantasies didn’t do anything for me anymore. Looking at beautiful women was not exciting. It was as if I was turned into a eunuch.”
After I researched the medical journals and textbooks on male menopause (the media term) or lowered testosterone levels (the medical term), I was able to get a much clearer and detailed history from Mr. I. A.
“Now that you ask, doctor, I have been extremely fatigued in the past year. I have no energy or stamina. I have so much trouble getting through a tennis match that I just don’t play it anymore. And yes, my wife and I have been getting into more fights and arguments lately. I seem to be very irritable with my kids, too.”
Mr. I. A.’s blood tests revealed a borderline diabetic tendency, also indicative of lowered testosterone. His blood pressure was normal, as was his thyroid level. Two blood tests for testosterone came back very low and confirmed a likely diagnosis of male menopause – testosterone deficiency.
Mr. I. B. presented me with another interesting case of ED. Mr. I. B. was a 51-year-old man with a three-year history of depression which was unresponsive to the standard dosage of antidepressant medications. His psychiatrist tried different types of drugs to help alleviate his severe depression and an increased amount of antidepressant medications still did not produce the desired lift in mood and well-being — but instead resulted in loss of sex drive, ED and difficulty ejaculating.
The attending psychiatrist then referred Mr. I. B. to me for a consultation. Mr. I. B. did not have the usual risk factors for ED, such as diabetes or high blood pressure. He did, however, have a low testosterone blood level. He also was suffering from medication-induced ED.
Within three weeks, I was able to gradually taper Mr. I. B.’s antidepressant medications down to nil and substituted testosterone undecanoate (Andriol™) oral tablets in their place. Not only was his depression gone, but his sexual functioning had returned to normal without any difficulties. And I am not exaggerating – three weeks was all it took to eliminate the depression and reverse the medication’s ED side effect.
These are exciting times in medicine today. Study after study is outlining the benefits of testosterone replacement, instead of, or sometimes in addition to, antidepressant medications for middle-aged and elderly men who have symptoms of depression. Results are often dramatic as the case of Mr. I. B. clearly pointed out.
A Special Case
Mr. I. C. was a special case, which I considered to be a real diagnostic challenge and one that required a full history to help establish the diagnosis. He was 25 years old with a story of ED that was typical for a diabetic or an elderly man.
Mr. I. C. told me that he went to another men’s ED clinic prior to seeing me and was offered injection therapy or vacuum devices. He declined both of these hardware items and came in to my clinic after watching me on a television interview.
First, his erections took a few minutes to react instead of the normal few seconds for other men his age. Second, he would lose the rigidity after five minutes and would often be unable to complete an act of sexual intercourse because his penis would slip out of his partner’s vagina. It was very unusual for a man as young as Mr. I. C. to have such significant ED complaints.
More questioning revealed the following important information: “I was married at age 22 but divorced last year. The erection problem was very rare at the beginning of the marriage but it occurred more frequently about a year before our divorce.”
I first assumed that Mr. I. C. was having marital troubles and that stress was likely the cause of his ED. But I was wrong.
Mr. I. C. began to elaborate, “My wife had an affair and one day she came home to tell me she wanted out of our marriage. As far as I was concerned, I thought our marriage was fine. I was shocked and hurt, and soon after that we got a divorce. But I was having erection trouble from time to time before my wife told me that she’d had an affair. Since the divorce, I’ve had two girl friends and the erections were still not good.”
Again I assumed the ED was related to the psychosexual traumatic stress from the affair and the divorce, but once more I was wrong. Two and two was not adding up to four because Mr. I. C. had ED before his knowledge of the affair, or the divorce. Something was missing.
I’m A Cop
Then I asked Mr. I. C. about his work. “I’m a policeman and my wife is also a cop. We worked shift work but because we were also on different police forces, it meant our schedules always conflicted. It was almost impossible to find a time for sex that coincided with our shift work schedules.”
That’s when Mr. I. C. gave me the missing piece of the puzzle. “And anyway, with our shift work I was always too tired to have sex,” he continued, “…sometimes I only get four hours of sleep because my body has trouble adjusting to the changing shift times of the police force.”
The puzzle piece was of course, sleep deprivation. It was causing a lowering of Mr. I. C.’s testosterone level below the minimum requirement of testosterone necessary for his sexual functioning.
Blood tests confirmed my suspicion of a significant lowering of testosterone during times of sleep deprivation for Mr. I. C. Some guidance on sleep-inducing techniques: relaxation and meditation, black-out window blinds, and certain foods before retiring, all helped Mr. I. C. to bring up his testosterone levels naturally and allowed for consistent sexual functioning.
MENOPAUSE A MISNOMER
Technically speaking, there really is no such thing as “male menopause.” Men don’t have monthly menses, or periods, like women do -so they cannot have a menopause. But there is a condition that does affect men, scientifically termed hypogonadotrophic hypogonadism. Other descriptive terms used are: Andropause, Viropause or Testosterone Deficiency Syndrome (TDS). These different labels essentially mean a loss of androgens, which are the most dominant sex hormones in men.
Some excellent books on this subject of male menopause are:
- The Male Sexual Machine, by Kenneth Purvis, M.D., Ph.D.
- Hormonal Health, by Michael Colgan, Ph.D.
- Male Menopause, by Jed Diamond, Ph.D.
- The Alchemy of Love and Lust, by Theresa Crenshaw, M.D.
- The Superhormone Promise, by William Regelson, M.D. and Carol Colman
- Maximizing Manhood, by Malcolm Carruthers, M.D.
- Viropause/Andropause, by Aubrey M. Hill, M.D.
- Look 1O Years Younger, Live 1O Years Longer, by David Ryback.
- The Testosterone Syndrome, by Eugene Shippen, M.D. and William Fryer
- Understanding Men’s Passages, by Gail Sheehy
In many areas of medicine (and life in general) we are faced with the common dilemma – which came first, the chicken or the egg? Andropause is either a brain phenomenon or a testicular phenomenon, but the end result is the same. Here’s what happens:
- The hormone from the brain (called LH or leutenizing hormone) designed to stimulate testosterone production in the testicles, is operating at a low level. Since 95% of a man’s testosterone production comes from his testicles, this results in testicular shrinkage or atrophy. The brain’s LH levels have been shown to decline in an isolated way, without other precipitating factors, or we could simply call it aging.
- The specialized Leydig cells of the testicles can decrease their production of testosterone independent of and in spite of high levels of the stimulating hormone from the brain. This can begin because of a primary genetic predisposition towards decreasing fertility –or again we could simply call it aging.
By the time a man has a definite and permanent decline in his testosterone blood levels, his testicles have shrunk significantly and the brain has given up trying to flog a dead horse. In other words, the stimulating hormones are usually low and the end product, testosterone, is also low. It really does not matter which came first, the chicken or the egg because the damage to the body and sexual functioning is the same. It is the recognition of male menopause which has to be addressed and treated.
TESTOSTERONE THROUGHOUT YOUR DAY AND THROUGHOUT YOUR LIFE
Testosterone production in little boys and little girls is very low. Then at puberty, the stimulation from the brain’s sexual precursor (stimulating) hormones leads to a rise in blood levels of estrogen and progesterone in girls and testosterone for boys. The higher testosterone in boys accounts for muscular development, enlargement of the penis and testicles, frequent erections, deepening of the voice, facial and body hair and odoriferous perspiration.
The highest lifetime level of testosterone both for men and women is between the ages of 15 and 35. Most of the testosterone in the bloodstream is tightly bound to proteins and cannot be used. Only 2% of the total circulating testosterone, referred to as the free testosterone, is not in a bound form. This tiny amount is considered to be the most active form.
New research is showing that there can be 40-50% of the blood testosterone in a unique form referred to as bio-available. This bio-available fraction of testosterone is reported to be loosely bound to proteins in the bloodstream and can be readily used by testosterone-dependent tissues and organs of the body. New diagnostic blood testing kits for bio-available testosterone are being developed to replace the existing total and free testosterone analyses.
Declines in testosterone can begin at age 30. The reports show declines of up to l% per year for total testosterone and 2% per year for the free or unbound testosterone fraction. There are many factors involved in this decline, which I explain later.
Also, the decline is not consistent in all men, with some men well into their nineties having youthfully high levels. Still other men can have significant fluctuations (downwards) in their levels in just a few short years. Nothing is static and nothing is written in stone when it comes to testosterone levels.
Testosterone fluctuates throughout the day by as much as 25%. Women, on the other hand, have estrogen and progesterone modulations on a monthly, not hourly basis. The highest 24-hour level of testosterone for essentially all younger and middle-aged men is from six to eight a.m. The lowest levels occur between two and four p.m. When testosterone begins to decline, the first thing to go is this diurnal (daily) variation. The testosterone levels for andropausal men become blunted and remain consistently low during both daytime and nighttime.
“Testosterone levels fluctuate throughout the day by as much as 25%. The highest level occurs from six to eight a.m. –the lowest levels occur between two and four p.m.”
One final point on the variations of testosterone levels. These variations can cause men to have sexual urges and erections anywhere, any time, day or night. In addition, because testosterone can fluctuate to such an extent and with so much frequency, the sexual urges for men can disappear just as fast as they are initiated.
THE DECLINE AND FALL OF THE TESTOSTERONE EMPIRE
Testosterone can be thought of as a car’s gas tank. A full tank of gas or a quarter tank will both allow the vehicle to perform in the same way. The car will run just fine as long as you maintain at least a quarter of a tank of gas at all times. Running out of gas in your car can be compared to running out of testosterone.
There appears to be a minimum level of testosterone that is necessary for certain physiological processes to occur. These include muscle, bone, brain and sexual functions. However, with testosterone there is a wide range of “normal” values. Likely this is because at the younger ages (20 – 35), there is more than enough testosterone to maintain fertility and male sexual functioning. When men age (and I remind you that testosterone levels begin to decline at age 30) their testosterone can reach below this minimum level.
In comparing men and automobiles (what else?), there are certain similarities and differences for various men and their bodies, just as there are for various men and their cars:
- Some men take good care of their bodies and as a result get good lifetime performance from their bodies.
- Some men do not take good care of their bodies but nevertheless are still blessed with good health and longevity.
- Some men take good care of their bodies but their bodies break down or “rust out” prematurely (early andropause).
- Some men will often take much better care of their cars than their bodies.
- Some cars are lemons, no matter how much maintenance is done or money spent.
- The body, if given a chance can repair and replace almost all cells, tissues and whole systems. The car of course, is another matter, i.e. gas guzzlers, rust heaps and money pits.
What would be ideal, (but not very practical), is to have a few blood tests performed at age 20 for testosterone. Then put the results in a safety-deposit box and open it 25 years later. In this way, you will have a record of what your ideal testosterone level is to maintain youthful performance. That figure is your ideal number, which might be higher or lower than your neighbor’s. A1so, the ideal number is usually well above the minimum level for your body.
The problem that many doctors who deal with andropause are faced with is deciding just how high or how low the level of testosterone should be for middle-aged and elderly men. The consensus so far is to maintain a level at least above the lowest level of normal for young men. The normal range for men ages 20 to 35 is 40 to 80 nml/l of free testosterone. This minimum figure, 40 nml/l, often becomes a mid-range figure for middle-aged men and a high-end result for elderly men.
One final point to understand regarding replacement of testosterone (which is coming up ahead) is that it must be individualized to be of maximum benefit. Too often doctors are looking solely at numbers, and not at the patient as a total man.
WHAT TO LOOK FOR IF YOU SUSPECT ANDROPAUSE
There are specific physiological signs and symptoms associated with male menopause, or andropause. They do not all have to be present in order to establish a diagnosis and initiate treatment. In addition, some men have certain symptoms that are more pronounced than others. Many signs and symptoms are specific to middle-aged men, such as mood changes and sexual dysfunctions, while others are specific to elderly men, such as balance problems and osteoporosis.
The following is a list of 10 signs and symptoms of testosterone decline:
- Increased fatigue, decreased stamina
- Decreased muscle strength
- Increased abdominal fat
- Sexual dysfunctions, especially decreased libido and often ED
- Coronary artery disease, heart attacks, strokes
- Osteoporosis, loss in height
- Alzheimer’s disease, memory loss, depression, irritability
- Balance problems, decreased visual-motor skills
- Decreased hearing, decreased vision
As I mentioned previously, not all of these conditions have to be present to make a diagnosis of male menopause. If you or your doctor begin to evaluate some of these particular symptoms, a clearer picture will emerge. Many doctors are not aware of some of the examples in the list, such as the increased incidence of heart attacks in many patients with male menopause.
The reason why lowered testosterone is associated with a greater number of heart attacks is due to an increase in blood-clotting factors that can plug up the coronary arteries.
“Testosterone is critical for libido, but not as critical for actual erections.”
An important consideration for this book, however, is the relationship that testosterone and male menopause have on ED. The medical research studies tend to show that testosterone is critical for libido, but not as critical for actual erections. While it is necessary for overall erection functioning, extra testosterone does not turn men into super-studs.
Remember the analogy to your car. If you have a full tank of gas or a quarter tank of gas, there will be no difference in your car’s performance. That is the way it appears to be with testosterone. There must be a minimum amount for adequate erections. Any more does not confer any advantage.
THE DECLINE IN TESTOSTERONE PRODUCTION AND AVAILABILITY
Now let’s examine the phenomenon of testosterone decline from the perspectives of how and why. Some of these factors are timeless and affect all the men on this planet. Others are specific to geographic locations. Still other factors are related to the continuous exposure of precipitating circumstances. Even one isolated circumstance or event can cause a decline in testosterone.
Here’s why testosterone is so susceptible to a decline:
The older you get, the lower your testosterone levels tend to be. This might be related to age itself as an independent factor or to the type of lifestyle that many elderly men lead. We cannot stop the aging process, but as I mentioned in the preceding section, as long as a minimum amount of testosterone can be maintained, sexual functioning can continue uninterrupted.
One mechanism that has been shown to lower sperm count and sperm morphology (composition and appearance) is the raising of the temperature in the testicles. The scrotum is the sac that houses the testicles and is designed to hang downwards and away from the body to keep the cargo (testicles) 1° F cooler than body temperature.
Tight underwear, tight jeans or pants or sitting for long periods of time (driving taxi or long-distance bike riding) can bring the scrotum up and more towards the body. This keeps the testicles warmer than they should be for proper functioning of sperm. It may even also affect the testicular ability to produce testosterone in the long run.
As boys grow into men and then into older men, they sit more on and off the job. Cavemen never sat very long. For one thing, chairs as we know them weren’t invented yet. Neither were jockey shorts. Cave men were always on the go.
However, once they stood upright on two legs instead of swinging through the trees like their primate ancestors, walking and running for miles and miles every day became the norm. How much walking and running do older men do today?
Learning a lesson from our caveman ancestors to keep physically active would help to improve our testosterone production.
Some men have a genetic predisposition for a more rapid decline in their testosterone levels. This can be due to a biological program built into all men designed to decrease fertility with aging. It is well known that sperm count and corresponding sperm motility decline with aging, which directly affects the ability to father a child.
Perhaps, similar to women, it was not meant for elderly humans to be the parents of young children. Perhaps being grandparents is the mechanism of choice for taking care of small children when we become middle-aged or older.
Some things in life are irreversible and the two things you cannot change are your parents and your genetic code (and you thought I was going to say death and taxes). A11 you can do is try to maintain your personal minimum testosterone level once you figure out what that number is. Blood testing at an early age will help to determine it.
Exercise stimulates testosterone production, but not for all men and not by all exercises. Studies show that intensive aerobic exercise, i.e. running a marathon, can cause a testosterone decline in 30% of men, including athletes. Weight resistance exercises, however, tend to promote higher levels of testosterone.
“Weight-resistance exercises tend to promote higher levels of testosterone.”
The heavier exercises involving the larger muscles of the back, arms and shoulders require testosterone to promote muscle mass and muscle strength. In turn, the greater the muscle mass, the higher the level of circulating testosterone. It becomes either an uphill spiral: more testosterone = more muscle mass; or a downhill spiral: less testosterone = less muscle mass.
Aerobic exercises (running, biking, etc.) require very little muscle mass. This is especially true for upper-body muscles. Leg muscles are the muscles of choice for aerobic exercise but do not increase substantially in mass from aerobic exercises. Weight resistance exercises can be done at a gym or fitness club, in your home or with specific isometric exercises. Weight training exercises must be done at least three times a week to be beneficial for raising testosterone, building muscle mass and improving erections.
As we age, we tend to accumulate more fat due to a decrease in physical activity and testosterone production. Research shows that overweight men have lower levels of testosterone than physically fit men. One theory suggests that this is due to the higher insulin levels associated with obesity.
Another theory involves a protein in the blood called sex hormone-binding globulin (SHBG), which increases as we age. SHBG binds and inactivates over 60% of the free active testosterone from the bloodstream.
To make matters worse and cause a further reduction in testosterone levels, HGH (human growth hormone) levels tend to decline with aging, and as HGH decreases, SHBG levels increase. HGH production is stimulated by protein and inhibited by carbohydrates – reason enough to begin a lower carbohydrate diet and lose excess storage fat.
Another hormone which has been the subject of a lot of recent research is the hormone called leptin. Higher leptin levels have been associated with increased storage fat. There could be a genetic predisposition to this phenomenon, but in addition, higher leptin levels and lower testosterone levels are correlated. So far, all we have is an association with lowered testosterone, and not a causal effect.
More sexual interactions stimulate more testosterone production. Conversely, lower testosterone levels ate related with less sex. Remember, the highest daytime level of testosterone is at 6 a.m. to 8 a.m., which is why many men wake up with an erection. That also helps to explain why many men have a strong sexual urge first thing in the morning. Women, however, have a higher sexual urge last thing at night. Go figure.
Men require more regular sexual episodes, with or without a partner to maintain adequate levels of testosterone. As with exercise, testosterone and sexual frequency are either an upward spiral or a downward spiral (sorry, no pun intended).
In the first part of my book SEX FOR LIFE (Apple Publishing), I went into many psychological and marital conditions that often contribute to less sex drive and less sex. These usually are insidious in that they occur slowly over time, yet suddenly manifest with infrequent sex and the resulting ED. The physiological process accounting for the decreasing libido and the ED from marital disharmony is often a lowered testosterone level.
“More sex stimulates more testosterone production.”
Since most of the testosterone production occurs during your sleep, if there happens to be sleep deprivation on a regular basis, your levels can be affected. Therefore, it is important to get the required amount of total sleep and REM (rapid eye movement or dream sleep) every night. For most people, seven to eight hours should be the minimum daily requirement. Catching up on Sunday mornings by sleeping in until noon won’t do it, for testosterone, or health in general.
To improve restful therapeutic sleep there are prescription medications available. But instead, I recommend natural sleep inducers and techniques. Two very good books which not only detail the importance of sleep but also provide ways for achieving and maintaining sleep on a natural basis are: Sleep Thieves, by Stanley Coran, M.D., and Power Sleep, by James Maas, M.D.
Here is some specific advice from these books to help you improve your sleep routines: take a hot bath before bed; avoid alcohol before bed and try warm milk instead (for the increased tryptophan that may increase your melatonin); avoid exercise before bed; have sex before going to sleep; and finally, when all else fails, try counting sheep.
(Editor’s note: Healthy Readers Book and Digest Club members can also listen to the 1 hour audio of Delta Wave Sleep Therapy music and sounds available HERE.)
Chronic illnesses, such as cancer, cirrhosis (liver damage usually from alcoholism), multiple sclerosis and emphysema all result in lowered levels of testosterone. This is likely due to the stress of the i11ness. And the longer the illness prevails, the lower the testosterone.
Remission or resolution of the illness as soon as possible is desirable, not just to recover from the disease itself, but to counteract the negative effects on testosterone levels. One condition that is seen very infrequently but still seen enough to cause trouble in regards to testosterone is malnutrition. Medically, this is referred to as the Tea and Toast Syndrome, where the diet is deficient in nutrients and vitamins found in fresh fruits and vegetables and protein containing foods. This can happen in elderly, independent men who live alone.
In my book I discuss the mandatory need for more protein, to help limit the detrimental effects of Syndrome X and also to make more nitric oxide for better erections. Remember, the proper balance of proteins, carbohydrates and fats is important for maintaining health, and has also been shown in medical studies to ensure adequate testosterone production.
Lowered testosterone is correlated with higher insulin levels and, of course, diabetes. Also, if HGH levels are lower, so is the testosterone level. An excellent book on growth hormone, is Grow Young with HGH, by Ronald Klatz, M.D.
There is considerable research going on today in the field of andrology, showing the mutual declines of growth hormone and testosterone. The medical studies clearly point out that both these hormones often decline together in the aging male. Growth hormone replacement therapy is not advocated at the present time for aging symptoms in men or for ED due to insufficient research.
However, men with higher levels of growth hormone have benefits similar to men with higher levels of testosterone, especially better erections. In addition, the mechanisms that you can initiate yourself (coming up later in this section) to improve your testosterone levels will also raise your growth hormone levels.
The following medications are related to ED or the lowering of testosterone:
- Beta blockers (blood pressure pills)
- Thiazides (water pills)
- H2 antagonists (stomach acid blockers)
- Selective serotonin reuptake inhibitors (SSRIs)
- Antidepressants (e.g., Prozac™)
Many doctors are not aware of the ED and testosterone depletion that occurs with these medications. There are many other excellent medications available that your doctor can substitute for the offending pills which lower testosterone. Ask your doctor to check the potential side effects of your medications, as well as your testosterone levels.
Physical stress from a major injury, a car accident or from an operation depletes testosterone. Sometimes the decline is dramatic and leads to emotional, physical and sexual complications. However the decline in testosterone does not necessarily translate into further troubles – physiologically or sexually.
Those patients with higher testosterone levels to start with (before the accident) usually have a faster recovery and develop fewer complications as long as their bodies are able to maintain an adequate level of the hormone after the injury.
“Continuous rejections, failures and criticisms all take their toll on men by lowering testosterone.”
Emotional stress is another way that testosterone is depleted. Continuous rejections, failures and criticisms all take their toll on men by lowering testosterone. At work, at home and even self-directed, put-downs abound. Constant exposure to negativity in the man’s environment can really drive down testosterone levels. Learning stress management and relaxation skills will go a long way in improving your resilience to any testosterone decline.
The concepts of competition, winning and losing have a strong relationship with testosterone. Right before an athletic competition, testosterone runs high. For the winners, it stays high. For the losers, it goes down. The same holds true in business affairs and other personal pursuits. Everyone knows that winning feels better than losing, but you probably never realized that testosterone was responsible for those feelings – even for women.
With subsequent contests in sports and business, the testosterone level will always rise again, but if you previously won, you will start at an even higher level. If you previously lost, you will start at only a moderately high level. Testosterone sampling done on athletes provides an explanation for winning streaks and losing streaks in sports. The same studies were done on courtroom lawyers, both men and women, and the winners had higher testosterone levels than the losers.
Competition drives testosterone production, but it becomes a double-edged sword. Just like being nervous before performing in a sports or business event, a little competition is good, while a lot is bad when it comes to testosterone levels. A good way to maintain proper testosterone levels is to find the right balance of competitive goal direction vs. competitive “win at all costs” drive. This proper balance will help avoid any diminishing returns in sports and business, which are the two dominant areas in men’s lives.
It’s only been in the last few decades that the many chemicals, by-products and toxins in the environment have been suspected of potentially being disease-promoting. The quality of the air, water and soil has deteriorated to dangerous levels in many places of North America – and everything in the air, water and soil contributes to our food supply. Some of the toxic products of modern industry and the inadequate disposal or storage of these compounds has led to various chemical sensitivity syndromes.
These syndromes can manifest themselves in both lowered sperm counts and testosterone levels. In addition, allergic reactions to some foods such as dairy and wheat products can cause specific immune changes, such as abnormal antibody responses at certain target organs. One of these organs can be the testicles, the main suppliers of testosterone. An overactive inflammatory response to allergic food sensitivities has been linked to the deterioration in testosterone production.
Here is one final point about environmental factors and testosterone: the meat industry which produces beef and chicken specifically has had good success over the past 30 or so years in making animals fatter and therefore heavier through the use of estrogen supplementation. The estrogen in the form of injections or supplements in the animal’s feed has been approved by health and drug safety boards around the world. However, there are reports in scientific journals that the extra estrogen found in the animals can disturb the human estrogen/testosterone balance in men and women who eat meat.
This has been associated with increased breast cancer rates in women. The higher estrogen has also been associated with lowered sperm counts and sperm swimming impairment. Finally, a skewed testosterone/estrogen ratio weighted with excess estrogen can interfere with testosterone physiology without dramatically lowering total testosterone levels.
For all these reasons, many farmers and livestock ranchers are switching to organic farming methods, natural pasture and free-range grazing. Also, many consumers (myself included) are eating substantially more organically grown vegetarian foods and obtaining high quality protein from tofu instead of from meat.
The thoughts above can be particularly depressing for many people. However, on an uplifting note, it’s also good to know that the human body is a very resilient machine and has built-in mechanisms to counteract and detoxify negative environmental conditions. Otherwise we would all be eunuchs.
Iatrogenic effect refers to a condition specifically and directly caused by medical treatments or diagnostic procedures. Side effects of medications and complications after surgery or medical tests are common iatrogenic conditions. Statistics reveal 5% of all illnesses are iatrogenic in origin. It is part of the price to pay for the progress of modern medicine. But remember, the good (in medicine) has far out-weighed the bad (iatrogenic effect).
With this in mind, there is a controversy going on in the urological community today about potential iatrogenic effects from vasectomies. A vasectomy is the male sterilization procedure. It requires a minor operation to permanently tie off both sperm tubes (epididymi). Sperm production continues uninterrupted in the testicle but sperm never leaves the epididymi.
Some reports showed lower testosterone levels and higher prostate cancer rates after vasectomy. Other reports showed no short term or long-term problems with vasectomy. The little guys (sperm) arrive at a dead end. However it is presumed that they are reabsorbed by the body. One theory which offers an explanation to the lowered testosterone levels following a vasectomy, is the increase in antibody immune changes directed against the testicles that are sometimes observed. This can damage the Leydig cell production of testosterone, lowering hormone levels.
There likely will not be a definitive answer on vasectomy and its association with lowered testosterone levels for a while yet. However, Urological Associations around the world currently endorse the vasectomy procedure for male sterilization as safe and effective.
Since a vasectomy is essentially a procedure that cannot be reversed, and it turns out to be a cause of your lowered testosterone, then you likely would require supplementation of testosterone (pills, patches or potent injections). A more important issue is not if vasectomies cause testosterone depletion, but in recognizing the depletion and treating it effectively and appropriately.
One final area related to testosterone lowering via an iatrogenic cause has to do with diagnostic procedures or testing that can cause damage to the hormone-producing cells in the testicles. Two special tests are X-ray tests of the abdomen (upper and lower stomach).
These tests are called an upper GI (barium swallow) and a lower GI (barium enema). Performing these tests results in a substantial amount of radiation directed towards the abdomen. There is a possibility that the testicles can be affected by this radiation. This is especially true for a barium enema.
I do not mean to alarm any readers with these statements on iatrogenic mechanisms for lowering testosterone. I am merely stating scientific facts and possibilities, the majority of which are not relayed by the medical profession to the public. A frank discussion with your physician should be the first step if you have any concerns about iatrogenic problems in your medical care.
ARE WE DOOMED?
No! In many men, testosterone can be produced once again to near youthful levels by the testicles. You cannot get any younger, but in many cases you can turn on and improve your growth hormone levels, your testosterone stimulating hormone (LH) levels and finally your testosterone producing cells in your testicles. If the brain’s systems for releasing the stimulating hormones are still functioning, then the entire system can fire up again.
Here’s what you can get started on:
- First, you can begin a weight-training program on a regular basis.
- Second, better nutrition will help you lower your tendency towards diabetes and help you lose weight.
- Third, you can ensure that you get more restful sleep.
- Fourth, having regular sexual relations with or without a partner is essential – use it or lose it.
- Fifth, check with your doctor to see if some of your medications need to be adjusted or changed.
- Sixth, begin to tackle your stressful triggers and minimize the effects that stress has on your body. Practice meditation on a regular basis.
These are all important factors which will potentially improve your present testosterone levels and prevent any further declines.
What if those particular lifestyle changes do not work for you? They sometimes don’t because in some men the testicles have simply reached their capacity for any extra production in response to stimulation. The testicular capacity to manufacture testosterone can be permanently turned way down to idle speed. In those cases, testosterone supplementation is an important consideration. There are three methods for testosterone augmentation, which I call the three P’s: potent injections, patches and pills.
“There are three methods for testosterone augmentation: potent injections, patches and pills.”
1. Potent injections
The injections are given in the hip either once a month or sometimes every two to three weeks. They work well, but do not duplicate the diurnal testosterone rhythm of being higher in the early morning hours and lower in the evenings. For most men on these injections, testosterone levels during the first two weeks are slightly, to significantly higher than normal. During the second two weeks testosterone levels are slightly, to substantially lower than normal.
When taking injections, many men feel really good for the first two weeks, but not up to par during the second two weeks. Hence, the shots are given every three or sometimes even two weeks apart.
However, with more frequent injections (every two weeks) the level of testosterone might be slightly higher than desirable and may cause problems with the prostate.
The patches are applied to the skin with a special adhesive and provide daily dosing of testosterone. They are readily absorbed but have demonstrated a moderate risk for skin rash. Some manufacturers advocate application of the patch on a shaved scrotum for better absorption.
For many men who are involved in sports, a shaved scrotum with a patch on it might provoke too many questions in the locker room which can be a limiting factor in the successful use of the patches. The patches are available in the US but not currently in Canada.
The newer pills, which are presently available in Canada but not yet in the US, have demonstrated good absorption, excellent tolerance and very reliable results. Taken two or sometimes three times a day, the daily variation of testosterone is well maintained. In addition, the specific oral preparation of testosterone undecanoate, bypasses absorption by the liver and therefore has no potential for liver cancer. This was a serious side effect (iatrogeny) seen in the earlier oral testosterone medications.
Testosterone replacement studies conclusively show marked improvement in bone density and muscle mass as well as less fat storage. In addition to increased energy reported by the men, sexual functioning also improved significantly.
For many men whose ED has been proven to be associated with lowered testosterone levels, oral replacement therapy and monitoring of the blood levels will often show improvement. Some studies show complete recovery of ED. Replacement almost always guarantees more libido and desire. Sometimes that is enough to start the ball rolling. Sorry about the pun.
In a recent study presented at the First World Congress on the Aging Male in Geneva, Switzerland, way back in February 1998, the use of oral testosterone undecanoate resulted in an increase in sexual activity in 85% of the patient group treated. In that particular study, the percentage of patients with ED engaging in sexual intercourse jumped from 0% before testosterone supplementation –to 55% after treatment!
However, there are side effects (iatrogenic) to consider with all the replacement methods. If the patches cause a rash, they have to be discontinued. And there is a slight increased risk of prostatic enlargement with testosterone replacement in some men, but luckily not in the majority of cases.
The medical studies are quite clear though, in showing that there is no significant change in the incidence of prostate cancer with testosterone supplementation.
The Coolidge Effect
I will end this segment on andropause with a story I found in the book, Love and Lust, written by Theresa Crenshaw, M.D. It has become known as the Coolidge effect.
President Coolidge and his wife were touring a chicken farm. Mrs. Coolidge asked the farmer why the hens laid so many eggs.
“Well,” replied the farmer, “the rooster, he does his job every night.”
“Oh,” said Mrs. Coolidge, “perhaps you should tell that to Mr. Coolidge.”
Then President Coolidge asked the farmer, “Tell me, does the rooster perform his duty with the same hen every night?”
“Oh no,” said the farmer, “the rooster does his business with all the hens.”
To that statement President Coolidge replied, “Perhaps you should tell that to Mrs. Coolidge.”
The Coolidge effect – the potential of new sexual conquests – occurs in men by stimulating their testosterone production. Since adultery leads to marital disruptions and polygamy is illegal in North America and Europe, having multiple female sexual partners for men is not a viable option. Even for single men, the potential for contracting sexually transmitted diseases and AIDS is prohibitive to putting more notches on your gun belt!
Then what can be done to take advantage of the Coolidge effect, achieve higher testosterone levels and still have loving relationships?
My advice is to work on improving love in your relationship, which will improve sex –and improving sex will improve love. While women desire more love and men desire more sex (in general), a compromise and a balance can still be achieved. In this way, men can maintain good testosterone levels, have better, more frequent sex and have stable loving relationships, all at the same time.
About The Author
David Saul M.D., has been featured on numerous television shows and is considered one of the world’s leading authorities on sexual impotence. Often referred to as the “Doctor’s Doctor,” he is Director of the North Scarborough Men’s Health Center, Toronto, Canada and author of the acclaimed best-seller SEX FOR LIFE.
Dr. Saul has a worldwide following and was a featured speaker at the Annual World Meeting of the International Society of Impotence Research held in Amsterdam. He was also the featured speaker at the World Congress held in Berlin, Germany, where he presented abstracts of his work on erectile dysfunction and loss of libido to physicians from around the world.
Dr and Mrs Saul reside in Toronto, Canada.