Hormone Replacement The fountain of youth? by Brock Strasser

[Taureau]

I've lost my mojo!
Fact: Primitive man lived for only about 18 years, if he was lucky.
Fact: Men in the late 1700s lived for about 35 years.
Fact: A century later, in the late 1800s, men lived around 42 years.
Fact: Today, the average American male can expect to live well into his late seventies.
Fact: That's a lot more time in which to get laid!

As the population of the United States and other industrialized nations becomes older and older, the science and the medicine surrounding aging is improving. We're making all sorts of new discoveries regarding what may cause aging, as well as how to stave off the effects of aging for as long as possible.

One of the apparent effects of aging in men is the gradual loss of the production of testosterone. Typically, the average human male will see about a 1% decrease per year in T levels starting at about age 40.(1) Although this decline seems slow, and not all men will end up hypogonadal as they age, the prevalence of testosterone deficiency in older men isn't insignificant. At least 20% of men over the age of 60 have serum testosterone levels below the lower limit of normal (300-1,100 ng/dl).

Over the past 20 years, there's been considerable interest in evaluating whether testosterone replacement therapy or male "hormone replacement therapy" (HRT) is beneficial for certain men in preventing or lessening some aspects of the aging process. Male HRT has become en vogue in recent months with the launch of new topical testosterone preparations, such as patches and gels. Some pharmaceutical industry analysts believe that the male HRT market could be a $2 billion per year industry in the US alone within the next few years. Yes, that's right: a two, and nine zeroes!

It would be easy to author a book regarding all of the wonders of testosterone throughout the human life span. However, the focus of this article is going to be on testosterone (or hormone) replacement for men who have age-related or idiopathic hypogonadism and what they can and should do to ameliorate this condition. I will only deal with male hormonal issues and won't discuss the aspect or role that human growth hormone may play in staving off the aging process.


The Quest for the Fountain of Youth Continues

As many of you may already know, I offer personal telephone consultations. Lately, about 40% of my consults have been men in their late thirties to mid-fifties who suffer from age-related declines in testosterone levels and are looking for a "magic bullet" to make them feel young and full of piss again.

If you're a person who falls into this category, I have some bad news for you: there's no magic bullet (pill, injection, or suppository). It's doubtful that anything can transform you into a modern day Ponce de Leon (he didn't find the fountain of youth, either, just Florida). Face it, you're on a slippery slope, and I believe that if you're lucky enough to live a long life, you'll inevitably experience moderate to severely diminished capacity, regardless of any current therapy. So you need to be realistic. There are therapies that can help you and give back some of the gusto that you had when you were younger. But, as you continue to age, even these therapies will probably become less and less effective.

The endocrine system (and, perhaps, testosterone in particular) has been deemed the "pacemaker" of male aging.(2) As T levels decrease, men experience things such as a decreased feeling of well-being, decreased virility, increased visceral fat, osteopenia, atherosclerosis, and impaired cognitive function. In fact, some studies have shown that a decrease in testosterone levels might even be associated with a decrease in visuospatial functioning and a deterioration of verbal skills.(3)

There are also direct relationships between lowered testosterone levels and impaired memory, inability to concentrate, periodic sweating, reduction of muscle mass and power, bone aches, and last—but certainly not least—sexual dysfunction.(4) You may even get the uncontrollable urge to watch "The View" or "Oprah." Quite obviously, none of these effects are desirable. We want to eliminate the effects entirely for as long as possible, or we want to lessen them as much as possible for as long as we can.

Since many things in the male human body are responsible for the secretion of testosterone by the testes, the question beckons: what are the causes of testosterone reduction as we age? Is it due to the testes themselves not being able to make testosterone in sufficient quantities, or is some other pre-testicular decline at the pituitary occurring?

In one study conducted at Veterans Administration Hospital in Seattle, Washington, 29 young (ages 22-35) and 26 elderly (ages 65-84) healthy men were studied. All of the men had a single, random blood sample drawn, and 14 of the men in each group underwent frequent blood sampling for 24 hours. Both mean 24-hour serum total and free testosterone levels were reduced in elderly men compared to young men, while estradiol and sex hormone-binding globulin levels were similar for both age groups. Also, luteinizing hormone (LH), a hormone that can indirectly cause the testes to secrete testosterone, was similar in both groups in regard to amount and pulse frequency of secretion.

Upon giving members in both groups 50 mg of oral clomiphene citrate (Clomid) for seven days, total testosterone levels in the young men increased by an average of 100%, and free testosterone levels increased by an average of 304%. However, in the elderly group, these values increased by only 32% and 8%, respectively.

This study suggested that major age-related changes occur in the hypothalamic pituitary testicular axis (HPTA) on the level of the testes and are manifested by a decreased responsiveness to luteinizing hormone.(5) So, it's probable that the age-related decline of serum testosterone levels are due to decreased activity in the testes.

How can the side effects of age-related male hypogonadism be reversed? Seems pretty simple, huh? Just give these men shots of testosterone, right? Not so fast. There's a lot more to it than just cranking Grandpa with an amp or two of Sustanon-250 per week.

In younger men who have unexplainable reductions in serum testosterone (idiopathic disease), Clomid may be an effective standalone therapy because the problem may not be at the testicular level. The correlation between testicular function and decreased serum levels of testosterone is generally only made in older men.

One area that I (along with many others) have been in error regards the relationship between testosterone and prostatic hypertrophy and cancer. I don't doubt that the gonzo amounts of androgens that bodybuilders ingest will eventually lead to them having prostate glands the size of potatoes. The question is whether or not replacement therapy levels (considerably less than what a bodybuilder would use) have a similar effect. The answer seems to be no, it won't cause prostate problems.

In a study conducted in Poland that was published in 1998, 30 men (average age 61.1 years) with low testosterone levels were given intramuscular injections (200 mg) of testosterone enanthate every two weeks for 1.5-6.0 years, with the average duration being 3.35 years. This study demonstrated an increase in bone density, libido, potency, and positive mood parameters and a decrease in total cholesterol and LDL cholesterol associated with testosterone enanthate use. In other words, by the end of the study, every Polish woman in town was walking funny.

Interestingly enough, those patients with coronary artery disease demonstrated a decrease in angina pectoris and nitrate (medication) requirement. But what was really interesting from a prostate point of view was that even though the average serum prostate-specific antigen (PSA) level more than doubled from 0.65 ng/dl to 1.35 ng/dl, there were no clinically manifested adverse effects on the prostate.(6) It's probable, though, that if the testosterone dose given was greatly increased, there would be prostate issues.

In another study conducted at the University of Iowa and published in 1999, testosterone therapy given to men for up to two years showed only mild increases in PSA over control values.(1) Thus, I'll go on record here as saying that the prostate issue, with regard to hormone replacement therapy, is probably really a non-issue for most men, at least when speaking about testosterone as replacement therapy.

 

[Taureau]

Is There a Doctor in the House?

If you're a man with a decreased level of testosterone who's lucky (or wealthy) enough to find a physician who's willing to help you, chances are that you still won't be getting optimum dosing for hormone replacement therapy. This is due to a variety of factors.

One factor is that physicians are reticent to prescribe an ester of testosterone because it's a controlled substance and has to be injected. Even at low dosages, there's now this societal stigma surrounding steroid use of any sort. From my observations, this reticence seems to be common. Thus, I've seen men "on HRT" who are only getting 50 mg of testosterone cypionate per week, or 100 mg of testosterone enanthate every second week. Usually, this is a grossly insufficient dose to bring these men back to normal or optimal functioning.

The other problem, and this is more insidious, is the "normal" range of total serum testosterone (300-1,100 ng/dl) being too wide. This leaves a lot of wiggle room. Most physicians are too focussed on laboratory results and pay little attention to clinical efficacy. For example, you may have felt "ideal" at age 20 because you had a testosterone level of 780 ng/dl. Now, at 45 years old, your level has hit the shitter at 266 ng/dl.

So, your physician gives you a small amount of testosterone cypionate, and the lab results come back that your T level is now 487 ng/dl. Okay, you're "normal" according to the charts, even if you still don't feel normal. It's also unlikely that you'll convince the physician to up your dose. This is too bad. I'd call upon all physicians to rely less on some lab test and more on clinical response. If the patient isn't "feeling" the effects of the therapy, then much of it is wasted.

Other physicians are keenly aware that this injection of exogenous testosterone has the potential to shut off the little remaining innate ability for the testes to produce endogenous testosterone. Since the idea of disturbing healthy or even minimally functioning testes (or other organs) is anathema to most physicians, some of these docs make their patients actually come off of therapy every four to six months for three to five weeks in order to "restore normal functioning." Meanwhile, these poor guys end up being miserable for a month or so.

A better way might be the concomitant use of Clomid with testosterone therapy. Even in older men in whom the response to Clomid is minimal, it makes total sense. This would, at the very least, minimize or eliminate testicular atrophy (which, if only from a cosmetic perspective, deserves consideration). It would also "trick" the testes into producing at least some testosterone through FSH/LH mimicry, even if this trick only results in a slight increase or no decrease.

Clomid also has the benefit of being a competitive estrogen agonist, so it would also minimize the chance of gynecomastia secondary to testosterone aromatization to estrogen. Clomid seems to be well tolerated at 50 mg per day by most men for extended periods of time. Some studies show that men who've taken the drug for a year or so suffer no adverse side effects, although I'd like to see a multi-year study conducted with this compound on a large number of men.

Alternatively, human chorionic gonadotropin (HCG) could be used to keep testicular size and some endogenous testosterone production. The disadvantages of HCG are that it needs to be injected frequently and offers no protection against gynecomastia. It also needs to be refrigerated.

I'd prefer to use Clomid. From both "ease of use" and clinical practice standpoints, this makes a lot of sense. Another important thing to remember is that to feel "healthy," some estrogen and even DHT is needed.(7) So, eliminating these hormones in entirety is probably a poor idea.

Some physicians also think that all steroids are created equal and it's acceptable to substitute, say, nandrolone decanoate (Deca Durabolin) for testosterone cypionate in treating men who require HRT. This is also probably a poor idea for most men. And, as any bodybuilder who's used Deca can tell you, don't expect to have much (if any) libido while using nandrolone. Sure, the effects on lean body mass that nandrolone imparts (and the way that it makes your joints feel) might be wonderful. But if it croaks an already depressed libido, it probably isn't a good choice for use in this situation.


Possible Help Without a Script

What if you're a man with a decreased testosterone level, and your physician won't help you? I'd say to keep searching until you find a doc who'll help. But in the mean time, there are a few over-the-counter supplements that you can use to potentially help ameliorate your situation.

I'd suggest that any man with a decreased testosterone level have his serum zinc levels checked. Zinc deficiency can lead to a marked decrease in serum testosterone. Although I've been terribly critical of the supplement ZMA in the past, I have to endorse it for use in this particular situation—but if and only if you're deficient in zinc. Personally, I don't think that ZMA will do much in younger men who aren't zinc-deficient, but it might be somewhat helpful for men at any age with depressed serum zinc and concomitantly depressed serum testosterone levels.

Another possibility is Tribex-500 by Biotest. I'm embarrassed to say, but I've never even used Tribex for more than a few days at a time. But I'm open to the possibility that it could offer an effect on LH/FSH levels and, subsequently, T levels, to a certain degree. I must admit that some of the lab results look interesting. However, I can't in good conscience endorse something whole-hog that I've never tried to any real degree. Anecdotal feedback to me is that Tribex either works really, really well in some individuals, as evidenced by surging libidos and frequent erections, or it doesn't do much in others.

My instincts tell me that the people who get the most out of Tribex-500 probably have depressed LH/FSH levels, and those with intact HPTAs wouldn't see as many effects. I'd really like to see some blood tests done on more people to find out exactly what's going on before commenting any further on this fascinating supplement.

I also suggest to most of my clients on physician-prescribed HRT to consider using a hydroxypropyl beta cyclodextran complexed (HPBCD) 4-androstenediol prohormone "nasal spray." Now, you can't buy this as an already neatly packaged supplement. You need to purchase a saline-based nasal spray at a pharmacy and the raw, bulk HPBCD 4-androstenediol.

A couple of squirts of this mixture (delivering 25 mg of 4-androstenediol) in each nostril will probably help most men feel "energetic" and "potent" within ten minutes. The effect is quite temporary, however, lasting an hour or two at best. So, this type of thing is best used when you know in advance that you'll be having sex. For example, say that you have a date with a stripper named Bambi whose augmented breast size exceeds her IQ. Having a few toots of your special nasal spray may help you out.

And finally, Androsol, the new topical 4-androstenediol that Biotest makes, should certainly be effective in increasing testosterone levels enough to get most men in the high-normal (or even supraphysiologic) range around the clock. You'd need only 50-100 mg of active ingredient, sprayed on once per day. The effect will be immediately felt and should last at least 16-24 hours.

Editor's note: For readers who want to use Androsol to gain additional lean body mass or increase athletic performance, the suggested dosage is higher. Biotest also recommends that athletes use it twice a day, instead of just once a day.

Remember, these supplements might be moderately helpful. But if you suffer—or think that you suffer—from a decreased testosterone level, you should still seek the assistance of a competent physician. I'd try to convince your doctor to give you weekly shots of the longest-lasting testosterone ester available to you—usually enanthate, but sometimes cypionate. I'd advise the physician to start the dose at 75 mg per week, then titrate upward until a clinical effect is demonstrated (don't rely solely on a lab value). I'd also highly suggest the use of Clomid as an adjuvant therapy in these cases.

The ultimate goal of male HRT is improved muscle strength and quality of life, thereby reducing mortality and morbidity, not merely getting your serum testosterone level to match "normal" on some lousy chart. I'm confident that we should see more and more future advances in male HRT. I'd expect synthetic and oral products to be developed that are just as safe as injectable testosterone, with less hassle.

As your favorite Vulcan says, "Live long and prosper."
by Brock Strasser