Why is my Testosterone Low?

Do I need Testosterone Replacement? The question of low testosterone is one of the most common concerns that I hear from my male patients.  Unlike women in this country, who have been indoctrinated into the habit of seeing a physician routinely, most men don’t seem to make it to the doctors office until the chest pain becomes unbearable, the growth gets too large, or something begins to happen that really gnaws at the heart of their identity.  

In many instances the motivating factor revolves around a man’s erectile function.  A man will complain that he is unable to maintain an erection for the duration of  lovemaking, is unable to ejaculate, or that he is unable to obtain an erection at all.  Is it any wonder that US sales of the phosphodiesterase inhibitor class of medications (Viagra, Cialis) in 2012 exceeded two billion dollars?  In fact, to underscore the scope of the problem, a current class-action lawsuit is in place over the pentagon’s spending of over $500,000 on this class of drug in 2014.  I guess that this redefines the concept of an office “perk”.  So what’s up, guys?  Why is it that everyone’s got the dropsies, and what can we do about it?

It is well known that over the course of a man’s life, his testosterone begins to decrease.  A general rule of thumb is that a man’s T decreases by 1% every year beginning at around age 30.  However there is extensive evidence to demonstrate that  testosterone levels around the world are on the wane, reflected in declining sperm count and motility (movement- whether they’re doing the dance or sitting idly by the walls of the ballroom), decreasing fertility rates, and increasing sales of medications with the names Cialis and Viagra.  But why is this happening?  The allopathic reflex is to hang a sign that says “testosterone replacement for men”.  Just give it back.  If you can’t get an erection, why not just give a medication that increases the blood flow to the penis.  Sadly the comprehensive thought process, and needed recourse is much more complex than that.

From a Functional standpoint, it is essential to examine several factors at play in the environment that could be influencing a man’s ability to become aroused, maintain an erection, and produce sperm that know where to go.  While it is easy to chuckle at the erection jokes borne from the prevalence of Viagra sales, the topic mandates a more encompassing look as to why this is all happening, beyond the simple recourse of prescribing a simple pill.  If you think about it, the future of humankind’s survival on this planet is incumbent on the readily available, nice turgid erection.  So what’s happening?

I feel that in order to answer this question, one needs to take a trip into the environment to look for the answers.  Some of the environmental discussions will begin right here in the USA, in our own homes, workplaces, and relationships as we examine the effects of stress on the male’s testosterone levels, erectile function and sexuality.  Several classes of pharmaceutical drugs, such as the beta blockers used for hypertension and heart failure, can affect erectile function.  Statin drugs, a 16 billion dollar industry in our country, block the production of testosterone directly by heading off the precursor molecule cholesterol at the pass.  But other answers are found in places like the Everglades, where we can look at the effects that the environment has had on male alligators.

I have often marveled at the stick-to-itiveness of graduate students, and their ability to assume the responsibility of numerous challenges as they pursue their research.  But an intrepid group of graduate students recently took it over the top, conducting a study measuring the penis length in young male alligators.  You read this correctly; there are graduate students measuring penis length in alligators.  I imagine that this would be a challenge from the start, but just imagine how difficult it must be to measure the penis length of a grumpy, slightly ticked-off male alligator with low testosterone and a shortened penis.  I certainly wouldn’t want to be the one to pass on that news.  But in 1996,  that is exactly what happened, and the result demonstrated that alligators are progressively developing more truncated, shorter penises.   

http://www.ncbi.nlm.nih.gov/pubmed/8713642

But why?  Certainly there is no male of any species who would benefit by a shorter penis and lower testosterone.  What could be happening?

The results at this point are speculative, but it is felt that the changes in penis length are due to the accumulation of estrogen-promoting toxins in the waters.  Pesticides and fertilizers are known endocrine disruptors, which is to say that they occupy the receptor sites for endocrine (hormonal) systems, but don’t allow the correct messaging to be transmitted to the cells as a result of this receptor binding.  In this study, alligators from the p.p’DDE- polluted Lake Apopka, had 24% smaller penises and 70% lower testosterone levels relative to the alligators in the more pristine waters of nearby Lake Woodruff.  The Apopka alligators have been shown to store high levels of this endocrine disruptor in their fat.   Is it possible that modern man is similarly being exposed to numerous endocrine modulators that are affecting testosterone levels?  I suspect that the answer is probably “yes”. 

We are likely exposing ourselves to excessive levels of pesticides and fertilizers in our foods.  The Environmental Working Group, using five independent laboratories, showed that in low income infants, their umbilical cord blood at birth contained 232 different environmental chemicals, with multiple overlap in chemicals between the infants studied.  I have included the reference below:

http://www.ewg.org/research/minority-cord-blood-report/bpa-and-other-cord-blood-pollutants

So do they just go away as we age?  This is unlikely.  One can reasonably surmise that we are slowly accumulating toxins, and over time overwhelming the body’s ability to eliminate these toxins.  The clinical manifestations are showing up in enlarging male breasts, withering erections, decreased sperm counts and alligators who come up a bit short on the “croc”.

But environmental exposures in the form of toxins may only be only a part of the picture.  A more salient exposure “closer to home” that is likely affecting testosterone is our exposure to stress and the production of cortisol, our “fight or flight” hormone.  This primary stress hormone directly influences a man’s testosterone levels.  Lets take a look at how this works. 

To begin with, testosterone is made out of cholesterol.  Yes, the same cholesterol which our physicians are assiduously trying to lower with the ubiquitous statin class of drugs is an absolute, undeniable prerequisite for the production of testosterone.   Cholesterol is converted into the hormone pregnenolone, and then into progesterone, which then diverges by two enzymatic pathways into either anabolic or catabolic pathways.  Anabolic steroids build things up, make muscles stronger, and produce the hormones DHEA and testosterone.  Catabolic, conversely, means the opposite: to break down.  In the times of stress, we are willing to take a catabolic tradeoff, breaking down our muscles to make the glucose and amino acids keep our brain and heart alive.  We accept somewhat weaker bones, a compromised immune system, decreased metabolism, and a lowered sex drive to make it through the lean, hungry months of Winter, or following a rough prolonged battle with a neighboring tribe.  What our body wasn’t programmed to do, however, was to tolerate ongoing stress, with a persistent catabolic state, for long periods of time.

As men, we reflect this heightened stress state in our mood, our waistlines, our concentration and our erections.  Stress causes measurable shrinkage in the hippocampus, a part of the brain that is our “hard drive”, storing memory, connecting relationships, and allowing for navigation.  Cortisol literally melts our bodies and our brains.

The good news is that much of this can be modified.  A comprehensive functional approach will not solely reach only for the panacea testosterone (which if administered incorrectly has its own distinct risks), but will look for ways to decrease the stress response, eliminate and avoid toxins, and to ensure that all biologic pathways are running smoothly.  By optimizing energetics, metabolic and hormonal pathways, and ensuring that toxins and hormonal byproducts are cleared, the male can begin to improve his testosterone.  Herbal adaptogenic herbs, sleep, and focused mind-body practices, can help to blunt the stress response and return the body to a anabolic state of growth and repair.   Minerals and nutrients, essential for the production of our bodies metabolic processes, can be optimized, again coaxing our physiology to a state of health, growth and repair.  Other herbs, such as Tongkat Ali, Ginseng, and Tribulus, have been shown in clinical studies to increase testosterone, either indirectly by modifying cortisol or through more direct means. 

Direct testosterone replacement may be required for a subset of men, but it is not a panacea.  Too often I have seen a man start with a course of testosterone therapy, initially basking in the feeling of a revisit with his youth, vigor, and sexuality.  But frequently when these other biological factors are not taken into consideration, the honeymoon ends in a month or two, as cortisol remains high, the hormone estrogen starts to rise, and the mood and sleeping problems slowly return.  The reflex response is generally to increase the testosterone dose, but this then becomes a slippery slope, with progressive risks to the patient and a progressive therapeutic failure.

In subsequent blogs, we will look at the irrefutable association between low testosterone levels and cancer, dementia and cardiovascular disease.   Do our hormones decline because we age, or do we age because our hormones decline?   I’ll leave that to the pundits.  For the time being, I am doing what I can to keep my testosterone levels as high as possible with a healthy diet, avoiding toxins and medications, rigorous exercise, and sleep; blissful, essential sleep.