Testosterone

Testosterone Definition:

• Testosterone is a steroid hormone belonging to the androgen group of hormones. It is found in both males and females and in mammals.
• Testosterone is primarily secreted from the testes of males and from the ovaries of females. Small amounts are also secreted by the adrenal glands.

It is the main male sex hormone and is an anabolic steroid.

Testicular Anatomy

1 Epididymis 

2 Head of epididymis

3 Lobules of epididymis

4 Body of epididymis

5 Tail of epididymis

6 Duct of epididymis

7 Deferent duct (ductus deferens or vas deferens)

Diagnosing low testosterone: Look at the man or go by the numbers?

• Often doctors will treat the numbers and not the patient.
• It is important to look at the symptoms of low testosterone [T] or low-T and not rely on 'magic' figures which may be wrong or may not be proportional to the severity of symptoms being felt by the man.
• If you have symptoms of low-T but your results are low-normal do you have low-T --- the answer is maybe.

Delaying treatment makes no sense in the light of new findings [see below]

• Delaying treatment when we now know the adverse clinical consequences of low testosterone makes no sense.
• Change in medical practice is often like a lumbering elephant - slow. Yet lives are at stake.
• A study published by The Endocrine Society which was a longitudinal 18 year study funded by the National Institute on Aging and the American Heart Association made the statement that men over 50 may not live as long if they have low testosterone²⁹.
• There was a 33 percent greater risk of death during the next 18 years in men with low testosterone levels when compared with men with higher testosterone levels. This difference in risk was independent of smoking, alcohol intake and level of physical activity or pre-existing diseases such as diabetes or heart disease²⁹.

An enlightened statement about testosterone use in adults comes from the American Association of Clinical Endocrinologists:

Therapeutic Trial or Clinical Trial of Testosterone

• The symptoms of low testosterone can be the symptoms of aging or due to other processes.
• Thus treating with testosterone may or may not have the desired effect but will be the only way to find out and to resolve that 'maybe' issue.
• However, if low testosterone is the cause of decreased libido or lethargy or a clouded mind or decreased exercise capacity or recovery from exercise - then testosterone replacement can make a dramatic difference in a man's life.
• Low testosterone has been implicated in increased diabetes²⁶, heart attacks²⁶, decreased longevity²⁶, osteoporosis²⁶, increased cardiovascular risk²⁶ and even more aggressive prostate cancer²⁷. However the primary reason to treat is to alleviate the symptoms of testosterone deficiency as described below.

Desire, Erection, Ejaculation: Testosterone is involved in all 3 areas

Decreased Libido

• A decreased libido is the hallmark of low testosterone.
• Libido is your sex drive and your desire to have sex with your partner.
• This could be either a decrease in the 'hunger' or passion for sex or simply that the frequency or intensity of sex has decreased.

Erectile Dysfunction

• You may not be able to achieve an erection [Erectile Dysfunction or ED].
• This is the second most common symptom of
  low-T ²⁶.
• If you need to stay focused or to concentrate greatly during sex to simply maintain your erection, then low testosterone may be to blame and a therapeutic trial may be worthwhile.

Difficulty achieving an orgasm, decreased intensity & decreased ejaculatory fluid

• Low-T may also lead to difficulty achieving orgasm.
• The intensity of the orgasm may be lower.
• Ejaculation may occur faster than expected or liked.
• Longer stimulation may be required to achieve orgasm.
• The amount of ejaculatory fluid may also be diminished with low-T.

Central Adiposity [troublesome fat in your midsection]

• Increased central adiposity- a slow but steady increase in fat gain around the midsection [in men and women] which can be difficult to shift in spite of diligent exercise and diet.
• Abdominal fat increases your risk for insulin resistance, the metabolic syndrome, diabetes, systemic inflammation, cardiovascular disease and hypertension -- these are deadly consequences of increased abdominal fat and are factors often ignored in medical decision making with regard to testosterone replacement in men.
• Fatty breast tissue may also develop as a result of low-T and conversion of testosterone to estrogen by aromatase in abdominal fat.
• The fat in this distribution can make things worse for a man. Fat in this area can convert androgens [male hormones like testosterone] to estrogen the female hormone - yes, this is right, a man can increase production of estrogen through an enzyme called aromatase in this body fat. This worsens sexual dysfunction and lowers testosterone increasing cardiovascular risk as well. Increased estrogen in middle aged men has also been implicated in the aetiology of prostate cancer.

Other non-sexual symptoms

• Fatigue - numerous other reasons need to be excluded.
• Decreased motivation.
• Loss of muscle strength and muscle mass: Inability to lift weights you were capable of previously lifting and poor recovery times after exercise.
• Low bone density [osteopenia and osteoporosis] - numerous studies have shown that low testosterone is associated with loss of bone mass and that testosterone treatment can reverse this. Have bone density tested prior to treatment.
• Low red blood cell count [anaemia] may occur with low testosterone levels as testosterone stimulates the production of red blood cells in the body. However, other causes such as low iron, vitamin B12 and folic acid need to be assessed as causes of anaemia and tests to exclude genetic causes such as thalassaemia need to be considered as well. But when all else has been excluded, the finding may just be a low testosterone level due to decreased red cell production dependent on testosterone. The reverse of anaemia may also occur with T treatment. If you are on T treatment and increased red cell production has occurred then donating blood on a regular basis may be all that is necessary to keep this under control.
  With regard to erythropoiesis by androgens, this study stated: 
  
  "It is concluded that two mechanisms underlie the stimulating actions of steroids on erythropoiesis; one through the production of erythropoietin and the second involving a more direct influence on the blood-forming tissues."
  
  So testosterone works by both increasing erythropoietin and in the bone marrow to enhance the effects of erythropoietin.²⁸

• Initially for treating testosterone deficiency, scrotal patches were used. The scrotum is the sac of skin surrounding the testes.
• Scrotal skin is rich in 5α-reductase the enzyme that converts testosterone to dihydrotestosterone [DHT] and for this reason using a scrotal patch or applying testosterone gel to the scrotum will result in high circulating DHT levels.²³
• The problem with DHT is that there is the risk of hair loss in men genetically susceptible to this problem.
• The good news is that patches applied to the skin [recommended not over bony prominences] or gels applied to the skin do not produce elevations in DHT and thus will not be a problem with regard to hair loss²⁶.
• Testosterone supplementation with gels, patches or injections have the potential to lower sperm counts. The reason for this is that the negative feedback mechanism to the pituitary shuts down LH production which normally stimulates the Leydig cells in the testes themselves to produce testosterone. This effectively ‘shuts down’ the testes and they then atrophy [shrink in size] with diminished to almost no sperm production.
• According to Dr Abraham Morgentaler, ‘alternative treatments are available to stimulate higher testosterone production in the testicles, which may lead to greater sperm production in some men.²⁶’
  
• Clomiphene citriate [Clomid] is a non-steroidal treatment that increases testosterone production within the testes and thus less likely to interfere with sperm counts and infertility.

Some Nutraceutical Possibilities for Treating Low Testosterone

• Because low-T can lead to numerous medical problems and not least the loss of quality-f-life due to decreased libido, loss of concentration and significant fatigue.
• It is fortunate indeed that testosterone can be modulated by a variety of naturally derived compounds.
• These compounds have their own specific way of helping increase testosterone levels through unique mechanisms that can be used in a synergistic way by combining these compounds.
• It has been suggested that Clinicians should actively and aggressively seek out symptoms and signs of low testosterone and then to get an objective level by blood testing in men as young as 35 years of age.
• Ask your doctor to view the QuickGuide on Testosterone. It is important to have blood tests done for free testosterone and perhaps check your PSA for prostate cancer. A physical prostate check-up by your doctor is also advisable before commencing treatment of any kind.Testosterone as such does not cause prostate cancer otherwise we would have a huge problem in our young men. In fact low testosterone has been associated with more aggressive forms of prostate cancer³. If you have a prostate cancer, then it is advisable not to boost testosterone levels.

References for Natural Testosterone Boosters:

1. Tikkiwal M, Ajmera RL, Mathur NK. Effect of zinc administration on seminal zinc and fertility of oligospermic males. Indian J Physiol Pharmcol. 1987 Jan-Mar;31(1):30-4.
2. Takihara H, Cosentino MJ, Cockett AT. Zinc sulfate therapy for infertile males with or without varicocelectomy. Urology. 1987 Jun; 29(6):638-41.
3. Morgentaler, A. (2009). Testosterone for Life, McGraw Hill.

• If hormone balancing or testosterone replacement is being considered, then due diligence needs to be shown to assess for existing hormone sensitive malignancies in the breast or prostate by a combination of blood tests, imaging and physical examination. Counsel the patient on possible side-effects of testosterone such as hirsutism or deepening voice [unlikely if testosterone levels are kept at an optimal range for the gender.]
• Get baseline blood tests done for Free and Total Testosterone; SHBG; Estrogen [E2]; PSA in men, LFTs; Full Blood Count [FBC or CBC- as red cell count can be low with low testosterone]; FSH and LH; TSH for an underactive thyroid; Ferritin [to assess for iron deficiency] --- If cardiovascular risk is suspected then a check for homocysteine [see under QuickGuides], hs-CRP and Fasting Insulin and Glucose would be worthwhile
• Follow-up check-ups and blood testing are mandatory steps to keep side-effects to a minimum and ensuring an optimal level of hormone.
• Use the lowest dose that provides an optimum response within the reference range quoted for 21 to 49 year old men - 37 - 85 pmol/L
• Remember to check SHBG when testing hormones - SHBG binds free hormones [estrogen or testosterone]. The higher the SHBG, the lower the free hormone level. Look for factors that increase SHBG levels.
• Accepted dogma should always be challenged!  In the case of not using testosterone in middle-aged men due to the fear of promoting a prostate cancer, the dogma has indeed been challenged. The extremely tenuous roots of this myth have been delved into by reviewing the original articles in the inner sanctum of Harvard's professional library, one that has an incredible archive of important medical research - the  Countway Medical Library. These oft cited references were used in absolute defence of the dogma. The slender threads of this misunderstanding have been severed one-by-one in this important book 'Testosterone for Life'.
• Compounding pharmacists are true professionals who can be of great assistance in terms of literature for hormone replacement. Can compounding pharmacists make a mistake - you bet! Should you avoid a compounding pharmacist because a mistake is made in the industry every now and then? How may recalls have you experienced from pharmaceutical companies who also make mistakes? Can we avoid them if they make a mistake? In both cases thank goodness mistakes are relatively rare and both industries have important roles in clinical care.

ARL Pathology - click on the link on the right. If you have a chronic illness or if you are feeling constantly unwell, and are experiencing symptoms or signs of low testosterone such as low libido or muscle weakness, or erectile dysfunction [ED]. Checking your testosterone status may just be that important step you need towards good health.

Testing takes out the guesswork in terms of your dietary needs, treatment or supplementation.

Free Testosterone [the main test]

It is generally agreed that free testosterone is the best indicator of the testosterone status of a man.

Free testosterone makes up 1 - 2 percent of the total circulating testosterone and is an excellent marker for the testosterone available to attach to cell receptors.

Total Testosterone - can be very misleading

Sex hormone binding globulin or SHBG is a protein that binds testosterone tightly as is shown in the graphic below. The problem lies in the fact that a very large part of total testosterone measured is in fact inactive testosterone bound to SHBG. The higher the SHBG, the more free testosterone is tightly bound to this protein and thus unavailable to cells.

The other problem with the total testosterone test is that SHBG increases with age. The Massachusetts Male Aging Study showed that SHBG increases by 1.2% per year. 

So it is very possible to have a normal total testosterone and yet have a low free testosterone test. Many a diagnosis of low-T has been missed because of reliance on total testosterone.

Other tests

Bioavailable testosterone is an indirect test that is a derived figure dependent on other tests. This test has been replaced by free testosterone.

Equilibrium dialysis is the gold standard test used by laboratory researchers but is very labour intensive and thus costly.

ARL Pathology - click on the link on the right. If you have a chronic illness or if you are feeling constantly unwell, especially so if you have an inflammatory disease such as arthritis, heart disease, diabetes or asthma and chronic lung disease. Checking essential fatty acid status may just be that important step you need towards good health.

Testing takes the guesswork in terms of your dietary needs or supplementation.

Possible Tests to investigate [your potential for chronic inflammation]

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