Baseline laboratory testing is mandatory. Aside from general laboratory studies such as blood count, lipid profile, kidney and liver function, specialized testing for prostate health (PSA), diabetes and inflammation need to be determined. In addition, baseline hormone levels of free testosterone, DHEA sulfate, Vitamin D and thyroid hormone need to be determined.
In older men, testosterone decreases not only in amount but in the way it is produced. In younger men peak hormone levels are usually seen in the morning, but as one ages this variation changes and levels are fairly constant all day. It is important to measure the level of free hormone, not only the total amount in the blood. The free hormone is what the body sees and responds to on the cellular level; the total hormone measurement represents a combination of both free and bound circulating hormone. Bound hormone is not very biologically active and is not the best indicator of treatment. Second, laboratories provide a normal range of hormone for each age group, usually ranged by decades (e.g., 30-40 years, 40-50 years, etc.). Restoration of hormones to 20-30 year old male levels is called optimization. Unlike competitive sport abusers who take anabolic steroids at extremely high levels (and have to deal with complications inherent to excess treatment), we strive to maintain physiologic levels, well within the normal range for young men. There is an abundance of medical literature attesting to the safety and efficacy of this treatment plan.
Testosterone is made in the testes. It circulates in the blood primarily bound to proteins and is not very active in this state. A small percentage is unbound and is called free testosterone. This is what the cells of the body see and respond to, and this is what is measured during treatment. The more the testosterone is bound to protein the less it is bioavailable and the less effective it is. Sex hormone binding globulin, or SHBG, is an important protein which binds or inactivates testosterone. As a man ages binding increases, which further diminishes the availability of free testosterone. In addition, as one ages testosterone production decreases, further diminishing its effectiveness. The overall result: loss of muscle mass, strength and endurance, weakness, loss of libido and sexual performance, as well as an increase in visceral (stomach) fat, with susceptibility towards osteoporosis and cardiovascular disease.
DHEA, short for dehydroepiandrosterone, is one of the most common hormones found in the body. Produced in the adrenal glands, it is actually a prohormone which the body converts to testosterone, estrogen and other products. It is a weak but important androgen or male hormone, demonstrating the same benefits and actions of testosterone. In addition, it has unique anti-aging benefits. Population studies have shown men and women with high levels of DHEA have greater longevity. Like other hormones, DHEA production decreases with age and men greatly benefit from its replacement. DHEA increases insulin sensitivity which reduces the risk of developing diabetes. It is cardio-protective and strengthens the immune system. There have not been any published studies to date which demonstrate harmful effects of DHEA replacement therapy.
Unfortunately, there is no free lunch with men’s hormone replacement therapy. The good news is there is no significant downside when these medications are given to raise levels to the upper end of the normal range for young men. When very high levels of hormone are the goal, however, such as with steroid abuse, complications are seen, primarily with an increase in red blood cell concentration in the blood. This can result in slowing of the circulation, blood clot formation and stroke. This is not seen when the goal of therapy is to reach the upper end of the normal range. Periodic monitoring is extremely important to prevent problems.
Androgen replacement therapy can substantially improve mood for the better, providing a greater sense of well-being and optimism. However, sometimes there can be an opposite effect, where sensitivity to even low doses can cause irritability, anger and even rage. However, this is usually seen with very high doses of androgens, and can be reversed quickly by simply lowering the dose of medicine.
In the skin, testosterone is converted to the potent androgen dihydrotestosterone or DHT. DHT, when elevated, can cause acne, stimulate hair growth and paradoxically in some cases, hair loss. These undesirable side effects may be dose or duration dependent and need to be watched for. Fortunately, if they occur they are reversible by decreasing the amount of medication or by temporarily suspending its use. In some cases acne can be blocked without having to lower the dose and allow for continuation of treatment.
Thyroid hormone is one of the most critical hormones in the body and influences virtually every cell and organ system. You can think of it as the overall regulator or thermostat which affects virtually every bodily function. As with all hormones, aging results in a deficiency, or more accurately an insufficiency in active thyroid hormone. This leads to well known symptoms of hypothyroidism such as lethargy, fatigue, depression, lack of concentration, hair loss, skin dryness and nail changes, weight gain, cold intolerance and constipation. In addition there can be elevation of triglycerides and cholesterol, with their implications for increased risk of heart disease.
Although production of thyroid hormone remains relatively stable during your lifetime, as you age the ability of your body’s cells to convert thyroid hormone to its active form, Free T3, diminishes. So there is really is no failure to make thyroid hormone, only the decreased ability of your body’s cells to convert it to the active form. Routine thyroid function blood testing does not usually measure the active hormone Free T3. This explains why men and women can have normal standard tests of thyroid function yet still be clinically hypothyroid.
But the matter gets even more interesting. Many people who are diagnosed as hypothyroid are prescribed synthetic thyroid hormone such as Synthroid®, Levothroid® or Levoxyl®. However, this still fails to address the body’s decreased ability to convert the synthetic thyroid to the active form Free T3, which explains why so many people on replacement therapy still have symptoms of underactive thyroid. The matter is solved by either supplementing their prescriptions with T3, commercially known as Cytomel®, or by replacing their medications with natural thyroid hormone compounded by a pharmacist or sold under the brand names Armour Thyroid® or Nature-Throid®. These naturally derived compounds have the proper proportion of all forms of thyroid to provide the correct amount of hormone replacement to fully treat symptoms.
Like all natural hormone replacement therapies, thyroid function must be closely monitored with monthly laboratory testing and consultation until ideal symptom relief and blood levels have been achieved. This requires a fine orchestration of all hormone replacement in men to reach the correct balance to feel better, look better and reduce your risk for heart disease, cancer and many of the degenerative diseases discussed earlier.
Vitamin D, or cholecalciferol, is not a vitamin but actually is a hormone. We are only now discovering the many benefits of this substance, which is primarily acquired through sunlight and certain foods. Long known for facilitating the absorption and metabolism of calcium to maintain bone strength, we are learning Vitamin D plays an important role protecting the heart and in cancer prevention. Maintaining mid to higher range levels of Vitamin D has been shown in many studies to decrease the risk of breast cancer in women. Comparable anti-cancer benefits remain to be seen with men, but studies indicate a high degree of cardiovascular protection in both sexes.
When mid-range blood levels are maintained there are no adverse side effects, but too much Vitamin D can raise the serum levels of calcium. Like all other replacement hormones, Vitamin D therapy needs to be monitored.
If you live in a temperate climate, such as the northeast United States, almost 80% of the population is Vitamin D deficient, that is, blood levels fall below the low end of the normal range. Furthermore, the use of sunscreen to prevent sunburn and skin cancer filters out much of the production of the natural hormone. The only foods that truly provide substantial natural replacement are cod liver oil and lots of wild Alaskan salmon. Virtually all other foodstuffs and food additives are woefully inadequate. Most people who live in this region require substantial supplementation in the form of gel caps or liquid ranging from 1000 units to 5000 units daily. In cases of severe deficiency, prescription doses of Vitamin D at 50,000 units once or even twice weekly are necessary to bring blood levels up to an ideal range.
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