|Men: You can use testosterone to treat lipoprotein disorders|
Testosterone is gaining wide acceptance for restoration of youthful vigor, increasing muscle mass, and improvement of well being.
But testosterone also offers some unique opportunities for correction of specific lipoprotein disorders. Here's what you need to know.
Testosterone—male hormone of youth
Testosterone levels in males peak in their teens and twenties during their reproductive prime. That's also the period of a man's greatest physical capacity, muscle mass, physical energy, libido, and stamina.
Starting at age 30, testosterone levels diminish gradually. By the time a man reaches his 70s, testosterone has dropped to immeasurable levels. Diminishing testosterone levels lead to loss of muscle mass, increased body fat, and reduced libido. Mood disruptions are especially prominent, with deeper swings into blue, depressed feelings, struggles with feeling beaten and overwhelmed, and fatigue. Reduced concentration, irritability, passivity, loss of interest in activities, and even hypochondria can also result.
These changes become perceptible after a man passes beyond his mid-40's. Some call this time the "male menopause" or "andropause". Though not as visible as a woman's transition to menopause, the changes are indeed distinct. Since there's no particular external cue like cessation of a woman's menses, most men simply dismiss the changes as "getting old".
Testosterone replacement can be a helpful way to reverse many of the phenomena of reduced testosterone: feel more vigorous, gain muscle strength, partially restore lost libido, as well as help control weight.
Testosterone is also a controversial hormone fraught with unfounded fears and misperceptions. It does not, for instance, convert normal men into "sex maniacs". It may restore a more youthful sex drive, perhaps similar to that experienced in your 30's, but—disappointingly—this is among testosterone's weakest effects.
Studies have shown that the lower your starting blood testosterone level, the greater the benefits. With rare exceptions, few men before age 40 will benefit from testosterone, as they still maintain healthy levels.
The rate of decline varies from one male to another. One 50-year old man, for instance, might have a blood level of 390 pg/ml, and another 50-year old could have a level of 50 pg/ml. It's the second man who will enjoy greater benefits because of the lower starting value.
From a heart health standpoint, potential benefits of testosterone replacement in men with lower starting levels include:
* A reduction in vascular tone and endothelial dysfunction—Testosterone increases the production of the natural arterial dilator, nitric oxide, and suppresses growth of smooth muscle cells in arteries (a constituent of plaque).1
* Improvement in abnormal resistance to insulin—This is the essential phenomena behind pre-diabetes and metabolic syndrome.2,3
* Reduction in total cholesterol of about 5%.
* A dramatic reduction in inflammatory proteins—Levels of tumor necrosis factor and interleukins, in particular, are considerably reduced.4
* Men with coronary disease have been shown to be more likely to have low testosterone levels. In one study, a marked deficiency of testosterone ("hypogonadism") was found in 25% of men with overt coronary disease (e.g., history of heart attack or procedures).4
What's your testosterone level?
Do you have to have low starting levels in order to supplement testosterone?
Not necessarily, but the dose should be adjusted to your level. The lower your starting level, the higher your testosterone dose. We aim for restoration of a blood level of testosterone of = 450–850 pg/ml, reproducing the level most men have in their mid- to late-30s.
We advise having three blood levels checked prior to testosterone administration:
1. Total testosterone
2. Free testosterone—Most testosterone is bound to blood proteins. The "free" fraction is unbound but is the active fraction.
3. Dihydrotestosterone (DHT)—a by-product of testosterone that may be a culprit behind prostate cancer risk.
If feelings of sadness, bloatedness, and weight gain are prominent, an estradiol level might also be considered. This is a form of estrogen that can be elevated, particularly in overweight men, and triggers these abnormal responses and may increase risk of heart disease. Estradiol levels =30 pg/ml are generally considered abnormal. Weight loss can correct an elevated estradiol, as can prescription "aromatase inhibitors", such as Arimidex®. A nutritional "supplement", chrysin (usual dose, 1000 mg per day), has been shown to reduce estradiol levels; however, there's little supportive data documenting its effectiveness and safety. Speak to your doctor about this issue.
If free testosterone is low but total testosterone is = 450, then weight loss may be necessary to increase the free proportion.
If DHT is elevated, be sure to have a thorough discussion of its implications with your doctor or urologist. Prescription inhibitors of this conversion (finasteride, dutasteride) that have also been shown to reduce prostate cancer risk might be considered.
Using testosterone for treatment of lipoprotein abnormalities
There are two areas where testosterone can be a useful tool for correction of lipoprotein abnormalities:
1) Lipoprotein (a) —or Lp(a), is substantially reduced by a limited number of treatments: niacin and testosterone (estrogen in females). Those of you with relatively low starting Lp(a) levels may do just fine with niacin alone. However, if your Lp(a) is in the higher range (>70 mg/dl or 175 nmol/l), or if you're among the 5% of men truly intolerant to the "hot flush" of niacin, then testosterone may be worth serious consideration. Testosterone is quite effective, usually resulting in a reduction in Lp(a) of around 25–40%. One drawback: Niacin also corrects the small LDL pattern, an important co-abnormality that heightens the dangers of Lp(a); testosterone will not directly correct small LDL, unless accompanied by weight loss.5
2) Correction of metabolic syndrome—Testosterone levels are lower in men with diabetes or metabolic syndrome ("pre-diabetes"). Testosterone replacement partially restores the body's responsiveness to insulin and thereby helps reverse some of the phenomena associated with diabetes and metabolic syndrome.2,3 Perhaps more importantly, if a man feels better—stronger, more energetic, brighter mood—he's more apt to exercise, be more active throughout the day, and be motivated to participate in health. He'll also be less likely to indulge in unhealthy habits. Men who begin with very low testosterone blood levels (<200 pg/ml) can experience a dramatic boost in mood and energy. We therefore view testosterone as a powerful facilitator of lipoprotein correction and plaque control.
Is testosterone safe?
Some concern has been raised that administration of testosterone may cause a hidden prostate cancer to grow, though the bulk of existing clinical data has not shown increased risk.6 Testosterone has even been administered to men regarded as high risk for prostate cancer without documentation of any increased risk when serial biopsies have been performed.7
Nonetheless, it is wise to have both a prostate exam and a prostate specific antigen (PSA) test prior to starting testosterone and annually thereafter.
How do I get testosterone?
Testosterone requires a prescription. It can either be formulated for you by special pharmacies ("compounding pharmacies"), or obtained as prescription patches, gel patches, or injections. (Prescribed dose depends on the form used and your response.) Avoid oral testosterone, as this is associated with serious liver side-effects. You may find that many doctors will shy away from prescribing testosterone to enhance your mood, energy, etc, and prefer to prescribe it only for a condition called "hypogonadism", which is a severe, abnormal lack of testosterone. A frank, open discussion with your doctor to discuss your interests may help persuade him/her to prescribe testosterone.
We have found testosterone useful for men over age 40 if the above symptoms are present and total testosterone level is less than 450 pg/ml, or if the "free" testosterone is low (in the lower half of the normal range for the laboratory used).
For a listing of compounding pharmacies in your area, go to www.pccarx.com, the website for the organization for compounding pharmacies. You can also call their Customer Service department at (800) 331-2498.
We've used the Women's International Pharmacy with great success. (Despite the name, they will provide male hormones.) They can be found at www.womensinternational.com or 800–279–5708, fax 800–279–8011. They will formulate a cream that is applied to the chest, arms, or neck. We usually start with a dose of 50 mg twice a day; doses can be adjusted by your doctor to achieve the blood level desired. (Our target: 450–850 pg/ml.) Your doctor simply faxes a prescription to them and testosterone is sent to you by mail.
Insurance reimbursement is spotty for testosterone replacement. If your starting testosterone level is below normal, your doctor may diagnose you with "hypogonadism", which somewhat increases the likelihood of insurance coverage. Most men, however, do not fall into this flagrantly deficient range and insurers therefore regard testosterone replacement as a "cosmetic" effort and will not provide coverage. Prescription patches generally run $3–4 per day. This is another reason why we've gravitated towards formulated testosterone creams, since they cost far less, usually less than $1 per day.
We are supporters of the public's right to use compounding pharmacies to provide hormones formulated to your doctor's prescription. In fact, we feel strongly that these so-called "bio-identical" hormones, or hormones that are human in structure and not horse, pig, or other animal, are superior. Though this is not an issue with men's hormones, it is a huge issue with female hormones, where it is exceptionally common for physicians to prescribe horse-derived and other non-human hormones.
In their exceptional greed, the Wyeth Pharmaceutical company has filed a petition with the FDA to bar the practice of compounding bio-identical hormones for you and your doctor. Predictably, Wyeth is the manufacturer of Premarin® and Prempro® synethetic hormones. If you would like to state your views to the FDA or to your state representative, the Women's International Pharmacy makes it easy at www.womensinternational.com/bhrt.html, or go to their home page and click the link.
1. Khalil RA. Sex hormones as potential modulators of vascular function in hypertension. Hypertension 2005 August;46(2):249–254.
2. Marin P, Holmang S, Jonsson L et al. The effects of testosterone treatment on body composition and metabolism in middle-aged obese men. Int J Obes Relat Metab Disord 16:991–997.
3. Simon D, Charles MA, Lahlou N et al. Androgen therapy improves insulin sensitivity and decreases leptin level in healthy adult men with low plasma total testosterone: a 3–-month randomized placebo-controlled trial. Diabetes Care 24:2149–2151.
4. Malkin CJ, Pugh Pj, Jones RD et al. The effect of testosterone replacement on endogenous inflammatory cytokines and lipid profiles in hypogonadal men. J Clin Endocrinol Metab 2004;89:3313–3318.
5. Zmunda JM, Thompson PD, Dickenson R, Bausserman LL. Testosterone decreases lipoprotein(a) in men. Am J Cardiol 1996 Jun 1;77(14):1244-7.
6. Tan RS, Salazar JA. Risks of testosterone replacement therapy in ageing men. Expert Opin Drug Saf 2004 Nov;3(6):599-606.
7. Rhoden EL, Morgentaler A. Testosterone replacement therapy in hypogonadal men at high risk for prostate cancer: results of 1 year of treatment in men with prostatic intraepithelial neoplasia. J Urol 2003 Dec;170(6 Pt 1):2348-51.. LINK' target='_blank' >trackyourplaque.com