Bioidentical Hormone Replacement Therapy (BHRT) – Testosterone
In recent years, testosterone replacement therapy has gained in popularity amongst andropausal men to improve their sexual function, sense of well being, muscle and bone mass and strength. In addition, it has also been found to be beneficial in preventing heart disease, diabetes, and Alzheimers Disease. There is a growing trend over the last decade for both men and women opting for the use of bioidentical, natural hormones for the treatment of andropause and menopause, respectively. The trend away from the use of conventional synthetic hormones towards bioidentical hormones has been driven by several factors including a global trend towards everything “natural” as seen in the increased interest in organic foods and complementary and alternative medicine (CAM).
The testosterone used in BHRT is identical to that produced in the male human body. Although bioidentical hormones have long been utilized in other countries, the United States has predominantly used synthetic hormones for the past 40-50 years beginning with the introduction of oral contraceptives in the early 1960s.
Before men start with BHRT, laboratory tests are necessary to determine if there is a physiological need for testosterone replacement. Both free and total testosterone are measured, along with DHT and SHBG. If free and total testosterone levels come back within normal limits, BHRT may not be necessary. However, if a man is experiencing symptoms of andropause and has lowered levels of testosterone, it may be necessary to start on BHRT.
A Prostate Specific Antigen (PSA) will also be run before beginning BHRT to determine if there is a risk for developing prostate cancer while supplementing with testosterone. There are mixed opinions in the medical field regarding the use of BHRT and its relationship to developing prostate cancer. Some experts believe that there is a stronger risk of developing prostate cancer while using testosterone, while others agree that testosterone does not cause prostate cancer. Clinical trials have demonstrated the latter, showing that PSA, the laboratory value most indicative of a potential cancerous lesion of the prostate, does not rise over 3-5 years of use of testosterone replacement therapy. These same researchers showed that prostate cancer seems to develop most commonly in older men when their testosterone levels are actually lowest versus highest. Despite the evidence suggesting that testosterone replacement therapy does not increase the risk of developing prostate cancer, BHRT should not be started on men who have a personal history of prostate cancer.
The methods of administration of BHRT of testosterone include oral administration, application of a transdermal patch, intramuscular injections, and the implantation of pellets containing testosterone under the skin of the buttocks. Oral testosterone is the most unfavorable method of administration, as it is poorly absorbed by the body. Most of the oral testosterone is carried from the intestines to the liver by the portal vein where the liver inactivates a sizeable portion of the hormone. An oral micronized form of testosterone suspended in oil can also be used which is slightly better than the non-micronized form, however it is still poorly absorbed when compared to the other routes of administration.
Testosterone injections are usually given as a shot into the muscle of the buttocks and are usually given at 2-4 week intervals. The number of injections is variable and depends on how depleted testosterone levels are in an andropausal man. Common side effects of testosterone injections can include swelling and rapid weight gain, increased or ongoing erection of the penis and nausea, vomiting and stomach pain. Often times this is not the most favorable method of administration due to the pain that the shots cause (the needle for injection is thick) and the side effects associated with it.
Testosterone pellets are implanted under the skin, usually of the buttocks, and their effects can last for 3 to 4 months and sometimes for as long as 6 months. Blood tests will be run periodically to determine if the pellets are working effectively and if there are any adverse effects. Side effects are similar to injectable testosterone and can also include abnormal hair growth, acne, anxiety, tingling and prickling sensation, decreased sperm count, enlarged breasts in men, and headache.
Testosterone cream or gels seem to be the most favorable route of administration of BHRT. They work best if applied daily on a particular schedule and are applied to the thin skin of certain areas of the body, including the thighs or the back, where absorption is best. These are the most effective as they avoid the pass through the liver and are absorbed directly into the bloodstream. In addition, they seem to mimic the natural rhythm of testosterone secretion that occurs the human body throughout the day. The male body produces the most testosterone during the nighttime during sleep, which is why men so often wake with erections in the morning. By applying cream just before bedtime a similar effect can be achieved.
Potential side effects can include those listed as above for the individual methods of administration. Other side effects can include a rise in hematocrit, the proportion of blood volume that is occupied by red blood cells. Therefore, BHRT is contraindicated in individuals with high hematocrit levels. The rise in hematocrit is less commonly seen with the transdermal (cream/gel) form of administration. It has also been shown that BHRT can cause sleep apnea in younger patients and less frequently in older patients. This is due to the direct effect on laryngeal muscles. Rarely, testosterone can cause breast enlargement in males, called gynecomastia. This is due to the fact that testosterone can be converted into estrogen which leads to breast enlargement if in excess in males. One of the main complications of BHRT is the possibility of sterility following treatment. This is because sperm production and hormone production by the hypothalamus can be inhibited once starting on BHRT. It should be discussed with your doctor if you plan on retaining the option of fatherhood because of this potential side effect.
There are many herbs and plants that have been researched and documented clinically that show beneficial effects in improving symptoms associated with andropause. The following is a list of some of the herbs that have been shown to be effective:
· Yohimbe (Pausinystalia yohimbe) – This herb is a well documented remedy for male impotence and lack of libido. Yohimbe works by increasing the amount of blood that flows into the penis and prevents blood from flowing out of the penis, thereby causing and helping to maintain an erection. It may also stimulate areas of the brain involved in sexual desire. It has also been indicated for depression, although at very high doses, which has been found to be unsafe. Because yohimbe works on blood vessels and the brain, it can cause dizziness, nausea, insomnia, anxiety, rapid heartbeat and increased blood pressure as potential side effects. It is good to be monitored while taking this herb, so talk to you doctor before starting to take this herb.
· Tribulus terrestris – Tribulus is an herb that has been used for thousands of years by Chinese herbalists and in Aruvedic medicine to increase testosterone levels through the stimulation of precursor hormones in the brain. It has been used to boost libido and raise fertility in men with low testosterone. Potential side effects are minimal but can include upset stomach and gynecomastia, or the enlargement of breasts in men.
· Saw Palmetto (Serenoa repens) – This herb is the most effective and well-researched natural remedy for BPH. It has been shown that saw palmetto is just as effective as Proscar in men with both mildly and severely enlarged prostate glands with mild to severe symptoms of BPH. This herb also has many less side effects than medications used to treat BPH and has a wide array of mechanisms of action. It helps to relieve urinary urgency, inhibits binding of DHT to androgen receptors in the prostate gland and exhibits mild 5 alpha-reductase activity. A study by Carraro JC et al (1996) concluded that saw palmetto does not have an effect on the actual size of the prostate, nor does it change serum PSA levels.
· Stinging Nettles Root (Urtica dioica) – Androgens such as testosterone and estrogen bind to sex hormone binding globulin (SHBG) and cause cell proliferation, leading to BPH and potentially prostate cancer. Andropause causes men’s SHBG levels to increase making him more susceptible to abnormal cell growth. The chemical constituents of Nettles root are able to bind to SHBG limiting the amount of testosterone and estrogen that can bind to it and influence cell proliferation. It has been shown that Nettles improves urinary flow, the amount of urine left in the bladder after urination, and decreases SHBG levels in blood.
· Pygeum (Pygeum africanum) – Pygeum is a plant that has been used frequently for both its affinity for the genito-urinary tract and for its role in boosting a man’s libido. By reducing the abnormally high levels of prostaglandins found in men with BPH, this herb helps to reduce frequency of urination, especially at night, dribbling and decreased stream of urine flow, and feelings of bladder fullness.
A healthy diet with a concentration on whole foods is key to achieving good hormone balance and vitality. A large proportion of the diet should be comprised of lots of leafy greens and other fruits and vegetables along with adequate protein sources, healthy oils and whole grains. Foods that impair hormone balance include harmful fats found in margarines and refined vegetable oils, packaged foods containing hydrogenated or partially hydrogenated fats and refined sugars found in most foods like bread and pasta. Organic foods, especially vegetables, fruits, beef, poultry and fish, should be eaten as frequently as possible as non-organic food sources often contain pesticides and herbicides that can have estrogen-like effects on the body and disrupt hormone balance. Milk and dairy products should be consumed in moderation as they also have been found to contain hormonal residues that disrupt normal hormonal biochemistry as well.
Although there are many vitamins and nutrients that are very important for adequate hormonal functioning, specific nutrients have been researched and found to be beneficial for men’s health and for counteracting the effects of andropause. A few of these nutrients are listed below, although this list is not all-inclusive. Your naturopathic doctor can discuss what other vitamins, minerals and co-factors are important for you to take to assist you with your andropausal symptoms
· Essential Fatty Acids – There is a group of fats that the body is incapable of synthesizing on its own known as “essential fatty acids” (EFAs). They include omega 3 (linolenic) and omega 6 (linoleic) fatty acids. EFAs are required constituents of every cell membrane in the body and are required to maintain the fluidity of these membranes, aid in producing and balancing hormones and play an essential role in managing inflammation. Classic signs of deficiency include depression, mood disorders, memory loss, hyperactivity, anxiety, dry flaking skin, inflammation, arthritis, decreased bone density, muscle spasm, food allergies, fatigue, increased body fat and most important to our discussion, hormonal imbalance. Prostate health is also directly tied to adequate essential fatty acid intake and levels in the body. A group of researchers recently found that men with Benign Prostatic Hyperplasia (BPH) have less omega 3 fatty acids in their serum and prostate cancer patients have substantially less omega 3 fatty acids compared to men without BPH or prostate cancer.
· Zinc – The prostate gland has a unique characteristic of storing high levels of zinc. Healthy prostate tissue contains higher concentrations of zinc than all other tissue in the human body. Therefore, it is no coincidence that the level of zinc in the prostate gland declines dramatically in patients with BPH and even more so in patients with prostate cancer.
· L-Arginine – L-Arginine is an essential amino acid that can be very effective for erectile dysfunction that can help to produce harder and longer-lasting erections and increasing libido. Supplementation with arginine has also been shown to improve low sperm counts and male infertility. Arginine promote the production of nitric oxide, a substance that opens up blood vessels in the penis much like the drug Viagra. But unlike Viagra, arginine is free of side effects like Viagra and is relatively inexpensive. Arginine also helps to stimulate the release of growth hormone which also acts to stimulate sex drive. For men, losing muscle mass and gaining more fat mass during andropause can be very frustrating. Arginine, along with a healthy exercise regimen can help to increase muscle mass and decrease fat mass.
Acupuncture is the oldest form of medicine, dating back thousands of years. It is an energy-based medicine which acknowledges the existence of unseen electrical energy in the body which flows in documented patterns and pathways. Disease occurs when there is an imbalance or blockage of energy. Acupuncture is used to treat many conditions ranging from pain relief to chronic disease, to addictions (e.g. smoking cessation). More importantly acupuncture is a great treatment modality to use in conjunction with the aforementioned therapies to treat hormonal imbalances and fertility problems in men, combat aging and stress and assist with insomnia, depression and pain.
Body Mass Enhancement and Athletic Performance
As mentioned previously, as men’s testosterone levels decline in andropause, their body’s undergo changes from what they once were in their 20’s and 30’s. Fat mass tends to increase, typically in the abdominal region, and muscle mass tends to decrease. It is of the utmost importance to continue with cardiovascular and weight training during the aging process to halt the progression of chronic disease and prevent other future diseases from occurring. However, this may be harder than it appears. Also as testosterone levels decrease, men’s energy and drive to exercise and perform also decreases.
East Valley Naturopathic Doctors’ Athletic Performance and Body Enhancement Program can start giving you the results you have been looking for. Under doctor’s supervision, and without the use of banned substances, a naturopathic physician will give you the edge that you have been looking for in your weight training or your athletic performance programs. You will be guided through the 6 week program where you will learn about proper nutrition and exercise that are necessary to put on 10 pounds of lean muscle mass, while boosting your energy, strength and stamina to levels you might not have been able to attain before. To attain optimal performance, getting the correct and highest quality nutrients for your body is essential. Besides diet and supplementation, hormones play a very important role in how well your body functions. If you have low hormones like thyroid hormone, adrenal hormones, or especially testosterone, you might not be able to function to the best of your ability. Through Bioidentical Hormone Replacement Therapy (BHRT) and other hormone adjustments via nutritional supplementation and other naturopathic interventions, we can help you to optimize muscle mass, increase your mood and stamina and enhance your libido as well!