What is testosterone?
Testosterone is the primary sex hormone produced in men's bodies. Testosterone stimulates the development of the penis and testes, growth of facial and pubic hair, deepening of the voice, changes in body-shape, growth of bones, and increased muscle mass and strength. It helps maintain sex drive and the production of sperm cells, and it may play a role in balding. Mood is also affected by testosterone, and low levels of the hormone can cause severe and prolonged depression as well as fatigue. Testosterone is produced mostly in the testes and a small amount is produced from steroids secreted from the outer part of the adrenal glands called the adrenal cortex. Women's ovaries also produce a small amount of testosterone.

How does the body know how much testosterone to make and release?
The testes receive chemical signals from the pituitary gland, which is located at the base of the brain. The pituitary gland receives signals from the hypothalamus. The hypothalamus secretes gonadotropin-releasing hormone (GnRH). This signals the pituitary gland to produce and secrete follicle-stimulating hormone (FSH) and luteinizing hormone (LH). LH signals the testes to produce testosterone. If the testes begin producing too much testosterone, the body sends signals to the pituitary telling it to make less LH. This, in turn, slows down the production of testosterone.

What is a "normal" level of testosterone?
Doctors check to see if a man's blood testosterone level falls into a generally acceptable range of values. Testosterone levels vary from hour to hour, so fluctuations can be seen in men with no apparent problems. Generally, the highest testosterone levels occur in the early morning hours, so measurements should be taken at this time. Normal ranges are determined in normal, healthy men between the ages of 20 and 40 or 45. How is testosterone measured?
If a doctor suspects someone is not producing enough testosterone, he/she will check if the total blood testosterone level falls into the acceptable range. The doctor also may instruct the laboratory to measure the amount of free or loosely bound testosterone (about 40 percent of the total testosterone is strongly bound to a protein called sex hormone binding globulin, known as SHBG; about 58 percent is weakly bound to another protein called albumin) and the amount of free testosterone (only about two percent circulates freely in the blood). Blood levels of SHBG increase with age, so older men may have a higher percentage of bound testosterone and a lower percentage of free testosterone. Bioavailable testosterone includes the non-SHBG bound testosterone or the sum of the testosterone, which is bound to albumin and free (unbound) testosterone. How does aging affect the body's ability to make testosterone?
Not only does the amount of testosterone produced decline with age, the morning spike of testosterone seen in young men is blunted in older men. The pituitary glands of older men also may produce less luteinizing hormone (LH), which decreases testosterone production. Testosterone in aging men is more likely to bind to sex hormone binding globulin (SHBG), which reduces the amount of bioavailable or freely circulating testosterone that is available to the body. However, aging also is frequently associated with increasing obesity, and obesity is associated with decreased SHBG levels. Thus, measurement of non-SHBG bound testosterone may be needed in aging, obese men.

Why would a doctor suspect that someone has a low level of testosterone?
Symptoms related to low testosterone include: decreased sex drive, erectile dysfunction (ED), lowered sperm count, increased breast size (a condition called gynecomastia), hot flashes, increased irritability, trouble concentrating, and depression. Men who have a severe and prolonged reduction of testosterone also may experience loss of body hair, reduced muscle mass and bone fractures due to osteoporosis. Certain medical conditions also can cause the condition.

Can low testosterone be seen in younger men, too?
Yes. Certain genetic conditions such as Klinefelter's syndrome, Kallmann's syndrome, and Prader-Willi syndrome can cause lowered testosterone production in boys and young men. In addition, testosterone production can be lowered by bilateral cryptochid testes injury, inflammation, and tumors. Chemotherapy and radiation therapy also may damage testosterone-producing cells. Finally, many patients who are HIV+ have low testosterone levels.

Can a low testosterone level cause other problems?
Studies have shown that men with low testosterone can become frail, lose muscle mass and suffer bone fractures due to osteoporosis. Some data have suggested that testosterone therapy can lead to increases in muscle mass and strength. Researchers also have shown that men who are testosterone-deficient may be more likely to experience depression and reduced quality-of-life than men who produce adequate amounts of the hormone.

If someone has a low testosterone level, how do they get it increased?
Supplemental preparations of testosterone currently are available in gel and patch forms that deliver it through the skin, as pills, or as preparations that have to be injected into deep muscle about every 7 to 21 days.

What is the next step for a man who has low testosterone?
An endocrinologist is a doctor who is a medical expert in treating diseases with abnormal hormone secretion and tumors of glands that secrete hormones. Board-certified endocrinologists are ideally suited to evaluate, diagnose, and identify a wide spectrum of medical, physical and psychiatric abnormalities responsible for causing male sexual dysfunction including a low testosterone level. To find an endocrinologist near you, visit The Hormone Foundation's "Find an Endocrinologist" physician referral directory at www.hormone.org (The directory is comprised of over 2,500 members of The Endocrine Society, the parent organization of The Hormone Foundation and the largest organization of endocrinologists in the world.)

Male Menopause Exists!

Talk about old wives tales! The idea that menopause is an experience exclusive to women sounds more like an old husband’s tale! As they watch their wives (mothers, sisters) go through the hot flashes, night sweats and mood swings of menopause, men may heave a sigh of relief that they don’t have to go through it themselves. But in the face of physiology, we know that men are not, in fact, immune to the hormonal fluctuations of middle age. The effect may be more gradual, unlike the rollercoaster many menopausal women find themselves on, but male menopause is a very real phenomenon and it has a name: Andropause. That’s the textbook term for the midlife ‘pause’ or decline in male hormone production of the Androgens—specifically testosterone and DHEA—the major players in maintaining both physical and mental health in men. During the same timeframe, estrogen (particularly estradiol) levels in males tend to increase as androgen levels decline. The result is a negative ratio between the two; a hormonal imbalance that typifies the Andropause profile and signals an associated risk of prostate disease.

Functions of Male Hormones

The androgens increase energy and decrease fatigue; they help in maintaining erectile function and normal sex drive and in their anabolic (building) capacity are instrumental in increasing the strength of all structural tissues—the skin, bones, muscles and heart. Men make more testosterone than do women, accounting for their generally greater muscle and bone mass. A proper balance of the androgen hormones also helps to prevent depression and mental fatigue. These are the hormones that help provide the virility, stamina and drive we associate with the male of the species. To make a long story short, they put the M in ‘macho.’

Symptoms of Andropause

Needless to say, testosterone and DHEA levels in short supply are going to have a big impact on all those attributes both physical and mental that makes men, male. If at the same time, levels of the female hormone estrogen are too high as is not uncommon during this time, urinary and prostate problems may begin to enter the picture.

Usually, what the andropausal male first notices is a subtle loss of sexual desire, along with a downward shift in strength and energy. Bouts of depression and anxiety, the feeling of being ‘tired but wired’ and a persistent lack of stamina are also common symptoms as the androgens downsize with age. The mid-life male quite often finds himself short on enthusiasm for the things he used to enjoy; work is not quite as challenging and exercise is tougher. Fatigue sets in more quickly and the only bedroom activity he’s really up for is sleeping through the night; a feat too often sabotaged by frequent visits to the bathroom. Thinning hair, shrinking muscles, wrinkles and an emerging paunch seem to go with the territory. He may feel rundown, anxious, edgy and achy. If his stress quotient is too high the male babyboomer may describe himself as ‘burned out,’ an indication that is cortisol levels are elevated. Now he is aging rapidly. One thing’s for sure: he is not feeling like his old self.

Restoring Balance: Hormone Testing and Treatment

The first step towards restoring balance is to test hormone levels so as to identify specific deficiencies and excesses and to what extent they are out of range. This can be done through saliva or blood spot testing (Order a test HTML) in which optimal collection can take place in the privacy of one’s own home and sent by regular mail for processing in the laboratory. Test results include a complete evaluation of hormone lab levels correlated with symptoms and hormone usage. The report serves as a rationale for patient and provider to determine the most suitable treatment for restoration of hormone balance and relief of symptoms.

Stress management, exercise, proper nutrition, dietary supplements (particularly of adequate zinc and selenium) and androgen replacement with physician guidance have all been shown to raise androgen levels in men and help to counter andropause symptoms.

Case studies from our files provide a snapshot of andropause: a 77 year-old man complained of excessive fatigue, lack of stamina, loss of interest in sex, despite his recent marriage to an attractive younger woman, and general mental lethargy. His saliva testosterone level was found to be extremely low and his estradiol (estrogen) levels were high, a profile commonly seen in late andropause. This man’ s cortisol tested low throughout the day. After consultation with his health care provider, he began supplementation with a bioidentical precursor of testosterone (androstenedione) with added progesterone to balance his excess estradiol (estrogen) level. He rubbed a physiologic dose (tailored to his individual needs) of this natural hormone gel into his skin every morning and included in his regime adrenal supports such as optimal nutrition, vitamins, morning walks and an earlier bedtime. Followup testing showed balanced levels of estradiol, progesterone and testosterone along with great improvement in symptoms. According to this man, the testing and restoration of hormone balance gave him back his zest for life.

A 53 year-old workaholic complained of loss of concentration, poor recovery from workouts, loss of muscle tone and flagging energy. His capacity for exercise was much reduced and his quality of sleep suffered from recurring urinary urge throughout the night. This man tested his IGF-1 for growth hormone levels, Testosterone, SHBG (sex hormone binding globulin) and PSA levels in dried blood spot (See Male Profile II www.bloodspottest.com). All levels were found to be out of range and out of balance in relation to each other. Stress management and supplementation with natural hormones was initiated. A topical gel to raise androgen levels, compounded with an aromatase inhibitor and progesterone to help lower estrogen levels resulted in a balanced ratio of testosterone to estrogen. Our workaholic lost weight, increased energy, improved muscle tone and reported an overall heightened sense of well being. His family and marital life thrived under the new regime.

References:

The Testosterone Revolution, Malcom Carruthers, M.D. (Thorsons)

The Testosterone Syndrome, Eugene Shippen, M.D. (Evans & Co.

A Woman’s Guide to Male Menopause, Marc R. Rose, M.D. (Keats)

Male Menopause, John R. Lee, M.D.