What're the treatment options for andropause?
Testosterone Replacement Therapy (TRT)
Both men and women produce testosterone. The amount produced by women is much smaller and production comes from the adrenal glands. A decline in the testosterone level is associated with decrease in sex drive and libido in both sexes. Testosterone replacement therapy (TRT) re-energizes the entire body, increases lean muscle mass, and reverses the fat accumulation and muscular atrophy characteristic of aging.
TRT also considerably improves the quality of life in men after middle age. The replacement of testosterone may also
prolong lifespan by reducing the severity of age-associated diseases such as osteoporosis and cardiovascular disease, which are among the leading causes of disability and death.
For men, replacement and restoration of testosterone level in men to the level of a 30 to 40 year old male has shown significant anti-aging effects. The normal blood level of testosterone ranges from 15-100 mg/dL in women and from 300-1,200 mg/dL in men.
Pre TRT workup should include a complete history and physical examination, together with a battery of blood test including male hormonal profile and cancer screening test such as PSA to rule out any relative or absolute contraindications to testosterone replacement therapy.
Various forms of synthetic testosterone have traditionally been used. These include oral, sublingual, intra-muscular injection, and trans-dermal patches. While these synthetic hormones have been widely used with beneficial effects, there are drawbacks to their use.
Oral synthetic preparations result in short-term elevation and undesirably high inter-individual and intra-individual variability of concentrations of testosterone. There are also commonly associated elevations of liver function test and abnormalities at liver scans. Despite this, oral preparations still constitute about a third of prescriptions filled in the United States. Some common forms are pure testosterone, methyltestosterone, sublingual methyltestosterone, and fluoxymesterone.
The injectable synthetic testosterone is esterfied. They are safe, effective, and the least expensive androgen preparations available. They require an injection into a large muscle. It is slowly absorbed and last longer. It takes effect over several days or weeks. Injections eliminate the natural daily diurnal rhythm of testosterone production-high at night and early morning and low during the day. Testosterone enanthate and cypionate are forms commonly used. They have comparable pharmacokinetics. Both result in supra-physiologic concentration of testosterone for 1 to 4 days after injection. A satisfactory regimen is to administer 200 mg of one of these esters once every two weeks intramuscularly, but a more physiologic replacement therapy would be 100 mg of one of these on a weekly basis.
Trans-dermal synthetic TRT systems are perhaps the most commonly used. It comes in the form of scrotal and non-scrotal forms. Clinical studies have shown that both are effective forms of androgen replacement. The advantage of the scrotal form is that it produces high levels of circulating DHT due to the high 5-alpha-reductase enzyme activity of scrotal skin. It also requires shaving of the scrotum. Inadequate scrotal size and adherence problems are limitations. Skin irritation does occur in those with sensitive skins. Non-scrotal skin patch's advantage is that the serum testosterone concentration profile mimics the normal circadian variation observed in healthy young men. Skin irritation is more common, with over 50 percent experience some form of site reaction sometime during the treatment. Pretreatment with corticosteroid creams (not the ointment forms) has been shown to reduce the severity and incidence of skin irritation without significantly affecting testosterone absorption from the patch.
Androgen replacement can have undesirable side effects, including frequent or persistent erections, nausea, vomiting, jaundice, ankle swelling, or virilization of female sexual partner. Breast enlargement can also develop as testosterone can be converted to estrogen via the enzyme aromatase. More serious complications include water retention, liver toxicity, cardiovascular disease, sleep apnea, and prostate enlargement. These risks are relatively uncommon when the dosage is closely monitored to that found physiologically in the body.
Androgens are contraindicated in men with carcinoma of the breast or known or suspected carcinoma of the prostate. They also should not be considered in those with known hypersensitivity to the preparation or in patients with compromised cardiac, renal, or hepatic functions.
While there is no direct evidence that link testosterone replacement to accelerated prostate enlargement, there is a correlation between testosterone treated hypogonaldal men and normal men with prostrate volume and age.
Prostate cancer is an androgen-responsive cancer, although there is no evidence to directly indicate that testosterone therapy causes prostate cancer. If prostate cancer cells already exist in the body, the disease may be stimulated to spread. Therefore, pre-treatment screening for any prostate dysfunction is mandatory. A digital rectal examination (DRE) and laboratory test for prostate specific antigen (PSA) should be checked before initiation of therapy and every 3 to 6 months thereafter. An abnormal DRE, an increase in PSA of more than 2 ng/dl, or a total PSA of greater than 4.0 ng/dl requires further urological evaluation. Other tests include hemotocrit, bone density, and plasma lipids on an annual basis.
Results of testosterone replacement may not be evident for several weeks. Impotence may not be corrected after several months of therapy despite improvement in other andropause symptoms. For these patients, evaluation for causes of erectile dysfunction other than hypogonadism due to andropause is indicated.
Close monitoring of serum testosterone levels should be carried out for patients on testosterone. Other signs, such as acne, increase breast size, and tenderness should be checked. After one week or more of trans-dermal TRT, serum testosterone levels can be measured about 12 hours after patch application and dosage adjusted accordingly. For oral methyltestosterone therapy, no assays are available to monitor therapy. For patients on the injectable form, nadir testosterone levels should be obtained 3 to 4 months prior to the next injection.
Recently, natural forms of testosterone have become available which possess all the benefits of synthetic hormones and little adverse side effects. They are available from specialized compounding pharmacy under the prescription of a physician.
The alternatives to testosterone include the testosterone precursors, androstenedione and androstenediol, which are available in oral capsules or sublingual sprays.
While testosterone replacement is one of the most effective ways to relief andropause symptoms and may be indicated in the aging male with documented hypogonadism, this hormone should not be used in those with normal testosterone levels. Under the care of a knowledgeable physician, this therapy is very safe for the vast majority of andropause patients.
Human Growth Hormone (hGH)
The quick way to reverse the declining human growth hormone (hGH) level is by hGH injections. A physician must monitor the injections. As with all hormones, growth hormone can be fatal if administered without proper precautions.
In particular, people with excessive lipids in their blood, diabetes, and abnormal liver function must have extensive medical workup prior to commencing treatment. The use of growth hormone also requires no pre-existing diabetes or cancer. The dose must be kept to a minimum or joint pains, heart failure or carpal tunnel syndrome may occur. Commonly used dosage is 1 IU per day by injection. This is a low dose, high frequency program that is quite different from the original study carried out by Dr. Rudman years back. Furthermore, for each five to six days of injections, there should be a one to two days of rest where the body is given oral supplementation such as secretagogue. The effectiveness of growth hormone therapy is measured through monitoring the IGF-1 level in the blood. This is the metabolite and marker of growth hormone. It is customary to try to achieve an IGF-1 level of 350 mg/dl as the end point in an anti-aging program.
While there is little doubt that growth hormone works, its use is not widespread due to its high cost and possible side effects if not monitored carefully.
Is there a natural way of replacing our growth hormone without drugs? Many physicians practicing anti-aging medicine believe so. These physicians believe in stimulating the pituitary gland to naturally increase the release of hGH. Substances that stimulate the pituitary gland in this manner are called secretagogues. Secretagogues are natural elements and side effects are rare. The results, though not as significant as injections, have been very encouraging. The replenishment of growth hormone from a deficient state can lead to an improved sex life; skin tone and can help to balance other hormones in the body including testosterone, DHEA, melatonin, pregnenolone, and progesterone.
Other ways to increase growth hormone release endogenously include intense strength training, cardiovascular exercises, calorie restrictions, and proper intake of nutraceutical supplementation, vitamins, antioxidants and amino acids such as glutamine, ornithine, and lysine that acts as a pro-hormones.
Many people have reported more energy, ability to handle stress more easily, think more clearly and generally feel better, after receiving DHEA. Other benefits include enhanced immunity (stronger resistance to colds, flu etc) and lower cholesterol levels.
DHEA's ability to rejuvenate the immune function is particularly worthy of consideration. It boosts antibody production; enhances the activity of monocytes and maximizes the anti-cancer function of immune cells known as T lymphocytes. When administered concurrently with a flu vaccine, DHEA has been shown to improve the effectiveness of the vaccine in laboratory animals and in aging humans.
One interesting note is that DHEA is not regulated by a negative feedback loop in the body. In other words, taking supplements of DHEA will not suppress the production of these hormones or cause the adrenal to rest and result in atrophy from the disuse. Theoretically, no "resting period" is required, although it is a good practice to have a resting cycle of a few weeks for every few months of therapy, as with all hormone replacement.
DHEA replacement therapy offers powerful health benefits and is virtually risk-free. The usual starting dose is 25 mg. Men may require a higher quantity (up to 100 mg) while women may need less (up to 50 mg). The ideal anti-aging strategy is to supplement both DHEA and its precursor, pregnenolone. Commercial DHEA products are made from diosgenin, an extract from the Mexican wild yam of the Dioscorea family. Biochemists can convert diosgenin to DHEA by engineering a series of chemical conversions, but such conversion only happens in the laboratory and not in the human body. The ingestion of Dioscorea plant extracts cannot possibly lead to the formation of DHEA in the body.
Numerous studies have shown the effects of pregnenolone on the body and brain. It boosts energy, elevates mood and improves memory and mental performance. Pregnenolone also creates a sense of well being while improving the ability to tolerate stress. Furthermore, pregnenolone has a host of advantages which includes the ability to influence cerebral function, energy level, the female reproductive cycle, immune defenses, inflammation, mood, skin health, sleep patterns, stress tolerance, wound healing. Taking pregnenolone therefore normalizes and rejuvenates the entire adrenal cascade.
The normal starting dose is 15 mg, increasing up to 100 mg for men or women. There are minimal side effects. A laboratory, although good, is not necessary for doses below 200 milligrams per day. Pregnenolone should be derived from a pharmacologically pure product and not a yam-derived "precursor." A very safe dose is between 25 and 100 milligrams per day.
Although pregnenolone has not been studied as extensively as DHEA as it is a precursor of DHEA and since it appears to decline as rapidly as DHEA, pregnenolone should also be considered in a comprehensive hormonal replacement regimen.
Pregnenolone is best tested for its ability to alleviate depression, improve moods and enhance cognitive performance. It also has corticosteroid-like anti-inflammatory effects without the joint-destroying catabolic effects of corticosteroids (Regelson, 1995).
It is often recommended for anti-aging purposes that both pregnenolone and DHEA be taken together. Since some pregnenolone is converted into DHEA, the amount of DHEA intake can be lowered if both are taken together.
One of the causes of the disruptions of sleeping patterns during aging is the reduction in the nightly release of melatonin by the pineal gland. Many people have discovered that bedtime doses of melatonin restored their ability to obtain a sound and peaceful night's sleep.
Melatonin levels are known to decline drastically with age. Since melatonin and FSH appear to be antagonistic in women, the same relationship may be true for men. It has been postulated that melatonin may even act to normalize (lower) gonadotropin levels. It is one of the few substances that have repeatedly been shown to extend the maximum lifespan of experimental animals. While low doses of melatonin (0.5 to 6 grams) act as a natural sleeping pill, high doses of melatonin (20 grams or more) have been used to fight cancer growth.
The exact dosage varies greatly between people. Trial and error is the best method. A higher dose does not mean more potency. Some people may feel better with a smaller dose. To normalize sleep and the bioclock, a good dosage to start is 1 mg and should be gradually increased if there are no side effects. A slight disorientation and dizziness may be experienced for the first few hours after waking up when melatonin treatment is first started. This sensation should go away after a few nights of melatonin use. If it persists, a reduced dose is recommended.
There are a few rules for the effective use of melatonin. Firstly, always take this hormone just before bedtime. If you take it earlier in the day, it may disrupt sleeping and waking cycles.
Normalization of Hypothalamic Function
The following substances are postulated to restore the hypothalamic (central) or peripheral (end organ) receptor sensitivity to testosterone. They are not commonly used as an anti-aging therapeutic modality due to the lack of long-term clinical studies into its effectiveness.
Alterations of catecholamine neurotransmitters (epinephrine, norepinephrine, dopamine) as well as a changing balance of the catecholamine/serotonin ratio have been postulated as the main cause of the loss of hypothalamic sensitivity by Dr. Dilman. Using selective drugs like MAO-B inhibitor, Deprenyl and neurotransmitter precursors such as the amino acids tyrosine, L-DOPA, and 5-HTP can normalize this.
Metformin is an oral anti-diabetic prescription drug. It is also a very effective anti-aging agent. Metformin acts by re-sensitizing the hypothalamus to negative feedback inhibition by steroid hormones. Used as an anti-aging agent, it has been showed that use in non-diabetic people results in lowered cholesterol and triglycerides, reduced glucose, and the prevention of atherosclerosis. Metformin may also increase testosterone levels by normalizing blood glucose and insulin levels. Some physician uses phenformin instead. This is a less effective analog of metformin, which has been shown to help extend the maximum lifespan of rats and mice.
Goat's Rue (Galega officinalis) is the herbal prototype of the biguanide class of pharmaceuticals that includes metformin and phenformin. It is believed that Goat's Rue would have the same effects as Metformin although there is a lack of sufficient research to substantiate the claims.
Puncture vine (Tribulus terrestris)
Tribulus is an herb that has been used for centuries in India as a treatment for both male and female sexual dysfunction. It has been widely tested for its efficacy in enhancing sperm quality and mobility. Tribulus has also been used to increase libido and sexual performance in experimental animals and men.
Studies have shown that tribulus administration has resulted in an increase of LH levels by 72 percent and free testosterone levels by 41 percent. While the exact mechanism of action is not known, studies have shown that it enhances spermatogenesis by enhancing the activity of FSH upon the Sertolli cells in the testes.
Tribulus also seems to stimulate the central nervous system directly to increase the secretion of LH thus resulting in an increased level of testosterone. It is also postulated that tribulus may directly sensitize the Leydig cells of the testes. These cells in turn produce testosterone in response to LH.
Other Male Reproductive Enhancers
Yohimbe has traditionally been used to enhance male potency and libido. It has acquired the reputation of being a male aphrodisiac and is listed in the Physician's Desk Reference (PDR) as such. It acts as an alpha-adrenergic stimulant. However, due to it's stimulatory property, the cardiovascular system is affected. Side effect includes increase heart rate, high blood pressure, and nervousness. Patients with hypertension, history of heart attack or stroke should consult a physician first before using Yohimbe.
Muira Puama is also known as "potency wood". It has long been used as a powerful aphrodisiac and nerve stimulant in South American folk medicine. Muira Puama may be effective in restoring libido and treating erectile dysfunction. Numerous studies have been conducted to validate this action. In one study, 262 patients with decrease libido and potency dysfunction were given 1 to 1.5 grams of oral Muira Puama extract. Within 2 weeks, it was shown that 62 percent of the subject reported benefits from Muira Puama. Unfortunately, the mechanism of action of Muira Puama is not known, and more studies are needed to ascertain its mechanism of action.
Men over 45 needs to be aware of the symptoms of prostrate cancer. Some 180,000 American men this year will be diagnosed with prostate cancer. 34,000 Americans will die from the disease. Prostate cancer is the leading non-skin cancer in men.
Benign Prostatic Hyperplasia (BPH) is a near universal disease of aging men. Men over 40 should have an annual digital rectal exam on their prostate and men over 50 needs to have a special blood test to screen for prostate cancer.
Prevention and enhancement of Prostatic health with botanicals is widely practiced in Europe and has been shown to be more effective than drugs.
Decades of studies and hundreds of clinical studies have shown that extracts from Saw palmetto, Pygeum africanum and Stinging nettle have all demonstrated efficacies when used in the treatment and prevention of benign prostatic hypertrophy (BPH).
Due to their multiple actions, it should be no surprise that when these botanicals are combined, they are even more effective than when used individually. An estimated 90 percent of men who have mild to moderate BPH experience some improvement in symptoms during the first four to six weeks of therapy.
Saw palmetto has been shown to have very few side effects. Since it does not interfere with PSA levels, saw palmetto will not hide cancer symptoms during PSA tests. Botanical should be seriously considered as a first natural alternative to drugs for those who wish to alleviate symptoms of BPH. These botanicals can also act as a prophylactic for those who are keen to prevent the onset of BPH. Healthy men about to or already in andropause should consider saw palmetto as part of a comprehensive anti-aging program.
Aging is a syndrome of degenerative disease characterized by age related diseases such as cardiovascular dysfunction, cancer and arthritis. One of the primary causes of aging is oxidative stress from free radicals. Through improper diet, external pollutants, stress of life, our body's cells are continually bombarded by millions of free radicals each day. The degree and the amount of free radicals present in the body are related directly to the speed of the aging process.
One of the primary goals of anti-aging is to stop the proliferation of free radicals through intake of food rich in anti-oxidants and antioxidants supplements.
While there is no established laboratory reference for the ideal intake level of antioxidants for anti-aging, many in the forefront of anti-aging research are advocating much higher levels of intake than the Recommended Dietary Allowance (RDA) set by the National Science Council. While each person is unique in his or her requirement, the following daily intake represents part of a common regimen of preventing heart disease and cancer, the combination of which accounts for more than 80 percent of all deaths.
People that live in the Mediterranean region have one of the lowest heart attack rates in the world. Their diet consists of 50 percent complex carbohydrates (fruits and vegetables), 25 percent protein (from plant source like tofu and fish like salmon), and 25 percent fat (from fish and olive oil). Their saturated fats, refined carbohydrates and sugar intake are very low. The Mediterranean diet is an excellent model for anti-aging diet.
Fruits and vegetables contain abundant antioxidants and phytonutrients. Fish contains essential fatty acids that are critical building blocks of neurotransmitters and hormones. Moderate amount of plant-based protein such as soybean is easy on the digestive system compared to red or white meat.
Our diet should be fortified with digestive enzymes such as amylase, cellulase and lipase, which may be needed to digest protein and enhance gastrointestinal heath. This should be part of the daily supplement intake. Reduction of sugar intake and avoidance of cigarette and alcohol are also important. Finally, a reduction of calories by 30 percent to achieve 5 to 10 percent below the ideal body weight should be considered.
Exercise, in addition to its cardiovascular benefits, also increases the level of hormones in the body, which include growth hormone, testosterone, DHEA and pregnenolone. Performing strength-training exercise is a key component to an anti-aging exercise program because of the above-mentioned effects. Without a doubt, exercise is the closest thing to the anti-aging magic bullet as one can get. Those who exercise regularly live longer. It's that simple.
Following an anti-aging exercise program incorporating flexibility training, cardiovascular training, and strength training program in a balanced fashion is the key. Do not overdo or ignore any of the three components. Each component is equally important for anti-aging purposes.