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Andropause, the Male Menopause
by Abraham Kryger, M.D.
Although most people know that Menopause has generated a large population of women who have excessive rates of bone fracture and CHD, men also suffer from these conditions. The male menopause or Andropause, is due to hypogonadism- low hormone levels. Andropause, the word, appeared in the literature in 1952 and is defined at the "natural cessation of the sexual function in older men." Andropause also refers to sexual regression in men over 40 due to dropping male hormone levels. Although there are a few very well-defined clinical syndromes of male hypogonadism which require androgen therapy, their use in other clinical situations, such as mild hypogonadism and hypogonadism associated with aging is less well established.
Endocrinologically, there is little difference between the irreversibly hypogonadal man and the post-menopausal hypogonadal woman. (1) Neither has adequate levels of hormones (androgens or estrogens) and they both can be expected to show similar deficiency states; i.e. hypogonadal men also tend to have frequent MI’s and bone fractures. Recently, evidence of a protective effect of testosterone against both heart attacks and bone fractures, has been reported. (2)
Low hormone levels of testosterone in men, have detrimental influences on both mood and mental abilities , including decline of memory, and loss of youthful sexual functioning. Studies have shown that the sexual aging process results in organic impotence, erectile dysfunction, ejaculatory and urinary problems, decreased sexual drive or libido and deterioration of the general physique.
About Testosterone, The Male Sex Hormone:
Testosterone is the principal androgen of which 95% made in testes, 5% in adrenals. It is synthesized from cholesterol at approximately 6mg/day and metabolized by liver and excreted in urine. Testosterone can be bioconverted into two other steroids at target tissues:
1. Dihydrotestosterone (DHT)- binds more readily to androgen receptors. Conversion is noted at prostate, seminal vesicles, pubic skin.
2. DHT is 10x more powerful than testosterone, thus conversion amplifies the action of testosterone. DHT may be responsible for MPB-male pattern baldness and BPH- benign prostatic hypertrophy,
3. Estradiol- an estrogen, 25% made by testes ,75% bioconverted in liver and in the brain from testosterone. Is responsible for aggressiveness in men. :
Testosterone is the hormone which regulates the structure of all body proteins and assures the development and integrity of the genitals in males. The adult testicles normally produce about 7-10 mg of testosterone daily. A deficiency below this level causes only modest changes initially such as an increase in weight, progressive aging of the face, muscular weakening and weakening of bone tissue. Lowered testosterone secretion causes low functioning of the body organs resulting in the eventual failing of memory and resulting irritability associated with general fatigue. The development of arteriosclerosis, varicose veins, hemorrhoids, increase in body fat, atrophy of the skin, systolic hypertension and increased cholesterol are aging associated changes of males that are reversible with testosterone supplementation. (3)
About Androgens and Estrogens:
Androgens and estrogens have similar metabolic effects in the liver where testosterone is enzymically converted into estradiol or E2. Estrogen compound, is a combination of three estrogen subtypes; E1-estrone, E2-Estradiol , the active "female hormone" and E3-estriol. Estriol is protective against breast cancer and its deficiency directly causes the hot flashes and nervousness associated with "the change". Estradiol causes breast enlargement in men as well as the female changes that occur in women at adolescence. During menopause, women typically experience hot flashes, but no similar consistent signal seems to appear in aging men as they develop hypogonadism. However, most men do experience hot flashes when hypogonadism is abruptly induced by pharmacological agents that rapidly abolish lutenizing hormone (LH). The absence of obvious symptoms and the slow course and unpredictability of the development of low testosterone or hypogonadism, may contribute to its lack of recognition and its attribution to "normal aging". (2)
Erectile Dysfunction= Impotence:
Three major sexual disorders exist in males.
1. Disorders of desire related to inhibited sexual desires.
2. Disorders of arousal or Impotence.
3. Disorders of orgasm such as premature ejaculation; the inability to achieve an orgasm and retrograde (backward ) ejaculation following prostate surgery.
Impotence, the commonest, is present in 30 million men and increases with ages over 50 years. Yet 75% of men will not disucss their sexual concerns. Organic causes are present in 85% of cases. Impotence is consistent with inablity to get or keep an erection more than 75% of the time.
Erectile dysfunction is usually due to inadequate blood volume filling up the spongy penile tissue. A non-erect penis contains about 8cc. of blood compared to a fully erect penis engorged with 62 cc. of blood! EIGHT TIMES the normal volume of blood is required for an erection! Therefore it is easy to see that any process which decreases blood volume to the penis or does not keep the blood within the penis, will result in unsatisfactory erections. Causes range from drugs, depression, deliberate control to dissociation in psychological impotence.
Erectile dysfunction is due to these "inadequate" erections. Erections require five different conditions coming together: stimulation, neurotransmitters, smooth muscle relaxation, increase in arterial flow and veno-occlusive ( vein valve closure to maintain the erection). Erectile function is dependent on the penis receiving its full dose of blood on a daily basis. If for some reason, erections do not occur during the night in REM (deep) sleep, then eventually these tissues will scar and atrophy. If we do not use it, we lose it!!!
Sex and Aging, to be discussed another time , is a complex process. The loss of sexual drive is one of the first changes most notice of "aging". This decreased libido and failure to awaken with erections is the foreboding of the " impotence experienced by hypogonadal men". An important fact to remember is that "wanting sexual activity and the maintenance of erection is normal regardless of age"according to Dr. Ron Ferris, Director of Human Sxuality at UC Irvine. Interestingly enough , this feeling tends to be accompanied in most hypogonadal men, not by frustrated sexual urges or complaints of frustration but rather by "passivity" according to Dr. Swartz.(1)
More than half of the healthy men over age 70 that he surveyed showed morning serum testosterone levels at or below 300ng/dl, the customary threshold of hypogonadism. (5) One of the earliest signs of impending impotence is ejaculation without full erection. In this type of early erectile dysfunction, men who notice that they are able to masturbate and ejaculate without full erection should be seen by their physician at once. The new drug, VIAGRA, prevents impotence by causing nightly erections in those men who took it .(6)
Impotence, Testosterone and Alcohol:
One of the major causes of impotence is heavy drinking. This pattern of alcohol use is common in 25% of American men at some time during their adulthood. The relationship between alcohol consumption and testosterone secretion has both reversible and irreversible components.
Serum testosterone abruptly rises to normal levels when high alcohol intake is discontinued but moderate alcohol intake does not substantially affect its level. However, the very low serum testosterone level –under 300ng.–was found in 62% of long abstinent ex-alcoholic men over the age of 60 and in only 15% of nonalcoholic men of the same age, indicating that past heavy drinking is associated with a reduction of the current morning serum testosterone level by an average of 122ng/dl.
The decreased testosterone level prevents morning erections from occurring. In an ongoing study, I have found that replacing testosterone to "younger level" restores morning erection frequency to a daily occurrence. There is also an associated increase in sexual drive but this effect varies with different age groups. (5) Men who had used alcohol heavily in their middle decades had much lover levels of testosterone than their counterparts who did not drink or drank moderately.
Therefore, alcohol induced hypogonadism is common and may affect many men over the age of 60. A moderate amount of alcohol is the equivalent of 1-2 ounces per day or 2-4 beers or glasses of wine or 2 shots of hard liquor. Women are much more sensitive to alcohol’s effects and no more than three drinks a week are recommended in order to prevent breast cancer.
Low Hormones and Heart Attacks:
The best-known consequences of hypogonadism in men are impotence and dwindling libido. However, both melancholia and psychiatric disturbances , from depression to psychosis, can also occur in association with testosterone deficiency. Perhaps the most dangerous consequence of hypogonadism in men is myocardial infarction (MI). Serum testosterone levels were about 90 ng/dl lower in patients who had suffered MI's than in those who had not. Results also suggested that low testosterone levels predispose to MI and are lower in men with severe coronary artery atherosclerotic disease than in controls. Very high blood levels of testosterone might protect against atherosclerosis especially in men over age 60. (2)
Testosterone is not the only androgen that appears to protect again MI. Estrogen exerts a profound effect by both lowering the "bad" cholesterols, raising the good cholesterols and decreasing clotting of blood and blood pressure in women. DHEA-Dehydro-epiandrosterone, a precursor of both testosterone and estrogen, has digitalis-like effects and strengthens the heart muscle. Together, testosterone and DHEA prevent the death of CNS nerve cells. This information suggest that there are beneficial systemic effects in maintaining blood levels of androgens similarly to the benefits of maintaining normal thyroid hormone levels.
Illegal and Legal Use of Testosterone Replacement:
"Androgen use is very prevalent in society. Much of this is due to androgen abuse among athletes and bodybuilders, where black market androgen abuse has reached epidemic proportions. Indeed, in various studies of high school boys, it has been found that 4-12% had used androgens at least once (JAMA 27O:12l7, 1993)."........"Despite the prevalence of legal and illegal androgen use, the science of androgen effects has greatly lagged behind the understanding of biological effects of estrogen and indications for estrogen replacement therapy. Female oral contraceptives have been in use for many years, but only recently have we seen studies regarding hormone contraceptive agents in men. " Dr. Dana Ohl, from the University of Michigan, stated at the onset of his lecture on Androgen Therapy in men.
Current polls indicating use of testosterone replacement, illegally by the following :
96% Professional Football Players
80-99% Male Body Builders
11% High School Football Players
6.6% High School Senior Males
The prescription and use of steroids is legal in the United States. The issue is clouded by the Anabolic Steroid Control Act of 1990, which criminalizes sale and possession of any anabolic steroid intended for non-medical use. Misuse of steroids in the sports world has led to stigmatization of their legitimate medical uses; however, some care must nonetheless be exercised in prescribing steroids. The best protection for a physician is to carefully document symptoms and test results and not to over prescribe any replacement therapy.
Black market worth $300-400 million annually. Half are counterfeit. Most said to come from Mexico. Labels often claim illegal importation despite local manufacture. Purity is questionable and users sharing needles run risk of hepatitis, HIV infection and subsequent AIDS, abscesses, cellulitis and death. (6) Potential steroid users are further advised that buying a known counterfeit steroid is a felony, as is buying a non-FDA approved steroid.
Testosterone has been found to inhibit clot formation by decreasing fibrinogen and hardening of the arteries by increasing HDL and decreasing serum triglycerides. (4) It also strengthens muscles beyond normal limits and testosterone is the androgen of greatest concentration in cardiac tissues. Testosterone can make heart muscle more resistant to death during ischemia through improved maintenance of cardiac output as well as decreasing the clotting mechanism. These advantages of testosterone replacement are also associated with a general feeling of well-being, greater strength and return of libido.
The anabolic effects of steroids are those that have a direct effect on the production of muscle mass. There is an increase in muscular strength and recovery from injury or stress. Androgenic effects of steroids include the development or increase of facial hair, the deepening of the voice, stimulation of sebaceous glands and some as yet ill-defined effects on brain tissue.
Anabolic/androgenic steroids, in the presence of an adequate diet, can contribute to increases in body weight in the lean mass compartment through the activation of protein metabolism. The gains in muscular strength achieved through high intensity exercise and proper diet can be increased by the use of anabolic/androgenic steroids in some individuals.
Dangers of Anabolic-Androgenic Steroid Use:
1.Kidney Disease
2.Serum LDLC Increase, HDLC Decrease
3.Hypertension
4.Cardiovascular Disease
5.Stunted Growth
6.Depression
7.Aggression
8.Acne
9.Male Pattern Baldness
10.Gallstones
11.In Male- Testicular Atrophy, Decreased Sperm Production, Gynecomastia
12.In Female- Hypertrophy of Clitoris, Facial Hair, Deepening of Voice
13.Peliosis Hepatitis- blood-filled cysts in liver
14.Cholestatic Jaundice
There are health problems in aging men associated with testosterone administration. Enlargement of the prostate, accelerated progression of undiagnosed prostate cancer, increased hematocrit and a variety of liver lesions can occur. Administering testosterone by intramuscular injection tends to avoid the liver toxicity seen with oral preparations. Administration of testosterone cypionate reduced HDL and synthetic androgen also increase total serum cholesterol. Synthetic androgens are not preferable to preparations of testosterone itself.
Natural vs. Synthetic Testosterone:
Natural testosterone has been available since 1938. Most of the anabolic (tissue building) steroids are synthetic analogs of natural Testosterone, the male hormone. Usually they are taken orally in large quantities which are dangerous and can cause serious liver diseases as well as organ failure. Examples of "roids" such as stanazolol, Winstrol or Android( methyltestosterone), are used by bodybuilders. Injections of nandrolone deconate, or Durabolin, have been available in the gyms of America for over ten years.
These anabolic (tissue building) hormones cause increased incorporation of new amino acids into tissue. This increased protein synthesis, results in growth or hypertrophy of the muscle. Injectable synthetic steroids both androgenic:
Testosterone Esters for Medical Use:
Because testosterone is rapidly metabolized by liver if taken orally or by IM injection, esters, which are more lipid soluble, are produced and injected in a peanut oil base.
A) Testosterone Propionate, is short acting, half-life of 3-6hrs.
B) Testosterone Cypionate (Depo-Testosterone, Virilon IM)
C) Testosterone Enanthate (Delatestryl, Testaval)
One injection can maintain normal serum levels of testosterone for 10-14 days. When used as a replacement, no apparent side effects. Nandrolone deconate is a synthetic testosterone , which transforms to produce both high levels of testosterone and more anabolic steroids. This results in transformation to excess estradiol which can cause gynecomastia (breast enlargement) in men. Testosterone’s action on the muscles has been observed by young male athletes who try to bulk up and recover faster.
Medical uses of anabolic include CRF patients to stimulate red blood cell production. Prevention of angioneurotic edema. Stimulation of protein synthesis (burns, trauma, cancer, AIDS) Men: Congenital Micropenis, Hypogonadism, Impotence, Sexual Libido
Women: Osteoporosis and Endometriosis, Fibrocystic Breast Disease and Breast Cancer.
Children: Stimulate linear bone growth and speeds up growth of secondary sexual characteristics, eg. penile growth and pubic and axillary hair.
Oral Androgens:
Oral androgens are not metabolized into testosterone but act directly on androgen receptors. Because they cannot be bioconverted into DHT or estradiol, they are not as biologically active. All androgens appear to act on same receptors, but tissue sites vary in absorption and metabolism. Oral androgens are used medically for those patients with bleeding disorders or intolerant of injections.
A) Methyltestosterone (Android, Metandren, Oreton methyl, Testred, Virilon)
B) Fluoxymesterone (Halotestin)
C) Danazol (Danacrine)
D) Stanozolol (Stromba, Winstal) Approved for veterinary use only in US
Testosterone Patches and a new alternative:
Natural Testosterone can be used safely in large doses by men who are deficient . Physiologic doses present no apparent health risks. A novel method of administration through a skin delivery system is now available pharmaceutically. (2) Testoderm© is a patch delivery system of natural testosterone. It delivers 4-6mg of testosterone daily and is applied to the shaved scrotum. Androderm® is a very similar preparation which can be applied anywhere. To mimic the normal pattern as much as possible, the higher levels of testosterone occur early in the morning. Androderm patches are applied each morning and result in a surge of hormone within a few hours of application.
Self-administration by this technique is safe but awkward. For hormone replacement in men, a new dihydroxytestosterone gel is being developed by Proctor and Gamble (7) and a natural testosterone cream, ** in rapid absorption polymers has been developed in various strengths up to 100mg (5). Testosterone pellets are also available for hormone replacement in men. Even more reliable , testosterone pellets , contain 25mg of a timed release testosterone ; they can be inserted beneath the skin to deliver testosterone over 4-months in a simple office procedure. (6). All the hormone creams are prescription items which need to be applied twice daily to maintain their 12 hour duration of action. The hormone testosterone is naturally derived from a food source, a Mexican yam , and is identical to that hormone secreted by the testicles.
Why See the Doctor for a Cream?
Side effects of any anabolic steroid depend on the extent to which receptors on target cells are stimulated. There are receptors on sebaceous glands, hair follicles, and muscle tissue and brain tissue. The side effects would then be increased acne, increased body hair growth and increased male pattern baldness, and increased muscle mass. Physicians are well advised to monitor liver function, even if oral steroids are not being used, and to withdraw the hormone or decrease the dosage in such cases.
It does not take much hormone to exceed the recommended physiologic dosage. Monitoring by a physician and regular blood tests are important to get the ideal level for each man. The longer lasting injectable preparations are synthetic steroid supplements and should be delivered intramuscularly by injection under physician supervision. These synthetic products do have various potentially dangerous side effects. Most of the effects are related to liver toxicity from excessive doses. Testosterone has a very large safety margin. Direct toxicity is unknown in men, however in women testosterone does cause masculinization and facial hair growth. Due to the fact that testosterone can be made from progesterone in the female, it has been used successfully as a female sexual stimulant in tiny doses, for women with decreased sex drive due to menopause.
A study is now underway by The Preventive Medicine Clinic of Monterey using the testosterone 10% rapidly absorbing cream. The testosterone cream is a prescription item and requires an early morning blood test to check the serum hormone levels before starting on the hormone therapy. (5) It is also recommended that the PSA (prostate surface antigen) and a DRE ( digital rectal exam) be done prior to hormone treatments of any kind to rule out an occult or hidden cancer.
References:
1. Low Serum Testosterone: a Cardiovascular Risk in Elderly Men. Conrad Swartz, Geriatric Medicine today/Vol 7. No 12/Dec. 1988.
2. Transdermal testosterone Substitution Therapy for male hypogonadism. Bals-Pratsch,M, Yoo YD, Knuth VA, Nieschlag E , 1986 . Lancet 4/943-946.
3. Transdermal delivery of Testosterone. Findlay JC, Place V, Snyder PJ, 1989. J. Clinical Endocrinolology Metab. 64; 266-268.
4. Berkow, Robert, MD, Editor, The Merck Manual of Diagnosis and Therapy, Fifteenth Edition, Merck Sharp & Dohme Research Laboratories, Rahway, NJ 1987
5. Morning erections and testosterone cream. A Clinical study in men with erectile dysfunction. Self published, Abraham H. Kryger, DMD, MD.
6. Bower, Bruce, "Pumped Up and Strung Out", Science News, Vol.140, No. 2, July 13, 1991
7. Barnhart, Edward R., Publisher, Physicians' Desk Reference, 45th Edition, Medical Economics Data, Oradell, NJ 1991
8. Erinoff, Lynda, Editor, and Lin, Geraline C., Editor, National Institute on Drug Abuse Research Monograph Series, Anabolic Steroid Abuse, US Dept. of Health and Human Services, Washington DC, 1990.
9. relating to testosterone use in impotence
10. illegal use of steroids by athletes.
by Abraham Kryger, M.D.
Although most people know that Menopause has generated a large population of women who have excessive rates of bone fracture and CHD, men also suffer from these conditions. The male menopause or Andropause, is due to hypogonadism- low hormone levels. Andropause, the word, appeared in the literature in 1952 and is defined at the "natural cessation of the sexual function in older men." Andropause also refers to sexual regression in men over 40 due to dropping male hormone levels. Although there are a few very well-defined clinical syndromes of male hypogonadism which require androgen therapy, their use in other clinical situations, such as mild hypogonadism and hypogonadism associated with aging is less well established.
Endocrinologically, there is little difference between the irreversibly hypogonadal man and the post-menopausal hypogonadal woman. (1) Neither has adequate levels of hormones (androgens or estrogens) and they both can be expected to show similar deficiency states; i.e. hypogonadal men also tend to have frequent MI’s and bone fractures. Recently, evidence of a protective effect of testosterone against both heart attacks and bone fractures, has been reported. (2)
Low hormone levels of testosterone in men, have detrimental influences on both mood and mental abilities , including decline of memory, and loss of youthful sexual functioning. Studies have shown that the sexual aging process results in organic impotence, erectile dysfunction, ejaculatory and urinary problems, decreased sexual drive or libido and deterioration of the general physique.
About Testosterone, The Male Sex Hormone:
Testosterone is the principal androgen of which 95% made in testes, 5% in adrenals. It is synthesized from cholesterol at approximately 6mg/day and metabolized by liver and excreted in urine. Testosterone can be bioconverted into two other steroids at target tissues:
1. Dihydrotestosterone (DHT)- binds more readily to androgen receptors. Conversion is noted at prostate, seminal vesicles, pubic skin.
2. DHT is 10x more powerful than testosterone, thus conversion amplifies the action of testosterone. DHT may be responsible for MPB-male pattern baldness and BPH- benign prostatic hypertrophy,
3. Estradiol- an estrogen, 25% made by testes ,75% bioconverted in liver and in the brain from testosterone. Is responsible for aggressiveness in men. :
Testosterone is the hormone which regulates the structure of all body proteins and assures the development and integrity of the genitals in males. The adult testicles normally produce about 7-10 mg of testosterone daily. A deficiency below this level causes only modest changes initially such as an increase in weight, progressive aging of the face, muscular weakening and weakening of bone tissue. Lowered testosterone secretion causes low functioning of the body organs resulting in the eventual failing of memory and resulting irritability associated with general fatigue. The development of arteriosclerosis, varicose veins, hemorrhoids, increase in body fat, atrophy of the skin, systolic hypertension and increased cholesterol are aging associated changes of males that are reversible with testosterone supplementation. (3)
About Androgens and Estrogens:
Androgens and estrogens have similar metabolic effects in the liver where testosterone is enzymically converted into estradiol or E2. Estrogen compound, is a combination of three estrogen subtypes; E1-estrone, E2-Estradiol , the active "female hormone" and E3-estriol. Estriol is protective against breast cancer and its deficiency directly causes the hot flashes and nervousness associated with "the change". Estradiol causes breast enlargement in men as well as the female changes that occur in women at adolescence. During menopause, women typically experience hot flashes, but no similar consistent signal seems to appear in aging men as they develop hypogonadism. However, most men do experience hot flashes when hypogonadism is abruptly induced by pharmacological agents that rapidly abolish lutenizing hormone (LH). The absence of obvious symptoms and the slow course and unpredictability of the development of low testosterone or hypogonadism, may contribute to its lack of recognition and its attribution to "normal aging". (2)
Erectile Dysfunction= Impotence:
Three major sexual disorders exist in males.
1. Disorders of desire related to inhibited sexual desires.
2. Disorders of arousal or Impotence.
3. Disorders of orgasm such as premature ejaculation; the inability to achieve an orgasm and retrograde (backward ) ejaculation following prostate surgery.
Impotence, the commonest, is present in 30 million men and increases with ages over 50 years. Yet 75% of men will not disucss their sexual concerns. Organic causes are present in 85% of cases. Impotence is consistent with inablity to get or keep an erection more than 75% of the time.
Erectile dysfunction is usually due to inadequate blood volume filling up the spongy penile tissue. A non-erect penis contains about 8cc. of blood compared to a fully erect penis engorged with 62 cc. of blood! EIGHT TIMES the normal volume of blood is required for an erection! Therefore it is easy to see that any process which decreases blood volume to the penis or does not keep the blood within the penis, will result in unsatisfactory erections. Causes range from drugs, depression, deliberate control to dissociation in psychological impotence.
Erectile dysfunction is due to these "inadequate" erections. Erections require five different conditions coming together: stimulation, neurotransmitters, smooth muscle relaxation, increase in arterial flow and veno-occlusive ( vein valve closure to maintain the erection). Erectile function is dependent on the penis receiving its full dose of blood on a daily basis. If for some reason, erections do not occur during the night in REM (deep) sleep, then eventually these tissues will scar and atrophy. If we do not use it, we lose it!!!
Sex and Aging, to be discussed another time , is a complex process. The loss of sexual drive is one of the first changes most notice of "aging". This decreased libido and failure to awaken with erections is the foreboding of the " impotence experienced by hypogonadal men". An important fact to remember is that "wanting sexual activity and the maintenance of erection is normal regardless of age"according to Dr. Ron Ferris, Director of Human Sxuality at UC Irvine. Interestingly enough , this feeling tends to be accompanied in most hypogonadal men, not by frustrated sexual urges or complaints of frustration but rather by "passivity" according to Dr. Swartz.(1)
More than half of the healthy men over age 70 that he surveyed showed morning serum testosterone levels at or below 300ng/dl, the customary threshold of hypogonadism. (5) One of the earliest signs of impending impotence is ejaculation without full erection. In this type of early erectile dysfunction, men who notice that they are able to masturbate and ejaculate without full erection should be seen by their physician at once. The new drug, VIAGRA, prevents impotence by causing nightly erections in those men who took it .(6)
Impotence, Testosterone and Alcohol:
One of the major causes of impotence is heavy drinking. This pattern of alcohol use is common in 25% of American men at some time during their adulthood. The relationship between alcohol consumption and testosterone secretion has both reversible and irreversible components.
Serum testosterone abruptly rises to normal levels when high alcohol intake is discontinued but moderate alcohol intake does not substantially affect its level. However, the very low serum testosterone level –under 300ng.–was found in 62% of long abstinent ex-alcoholic men over the age of 60 and in only 15% of nonalcoholic men of the same age, indicating that past heavy drinking is associated with a reduction of the current morning serum testosterone level by an average of 122ng/dl.
The decreased testosterone level prevents morning erections from occurring. In an ongoing study, I have found that replacing testosterone to "younger level" restores morning erection frequency to a daily occurrence. There is also an associated increase in sexual drive but this effect varies with different age groups. (5) Men who had used alcohol heavily in their middle decades had much lover levels of testosterone than their counterparts who did not drink or drank moderately.
Therefore, alcohol induced hypogonadism is common and may affect many men over the age of 60. A moderate amount of alcohol is the equivalent of 1-2 ounces per day or 2-4 beers or glasses of wine or 2 shots of hard liquor. Women are much more sensitive to alcohol’s effects and no more than three drinks a week are recommended in order to prevent breast cancer.
Low Hormones and Heart Attacks:
The best-known consequences of hypogonadism in men are impotence and dwindling libido. However, both melancholia and psychiatric disturbances , from depression to psychosis, can also occur in association with testosterone deficiency. Perhaps the most dangerous consequence of hypogonadism in men is myocardial infarction (MI). Serum testosterone levels were about 90 ng/dl lower in patients who had suffered MI's than in those who had not. Results also suggested that low testosterone levels predispose to MI and are lower in men with severe coronary artery atherosclerotic disease than in controls. Very high blood levels of testosterone might protect against atherosclerosis especially in men over age 60. (2)
Testosterone is not the only androgen that appears to protect again MI. Estrogen exerts a profound effect by both lowering the "bad" cholesterols, raising the good cholesterols and decreasing clotting of blood and blood pressure in women. DHEA-Dehydro-epiandrosterone, a precursor of both testosterone and estrogen, has digitalis-like effects and strengthens the heart muscle. Together, testosterone and DHEA prevent the death of CNS nerve cells. This information suggest that there are beneficial systemic effects in maintaining blood levels of androgens similarly to the benefits of maintaining normal thyroid hormone levels.
Illegal and Legal Use of Testosterone Replacement:
"Androgen use is very prevalent in society. Much of this is due to androgen abuse among athletes and bodybuilders, where black market androgen abuse has reached epidemic proportions. Indeed, in various studies of high school boys, it has been found that 4-12% had used androgens at least once (JAMA 27O:12l7, 1993)."........"Despite the prevalence of legal and illegal androgen use, the science of androgen effects has greatly lagged behind the understanding of biological effects of estrogen and indications for estrogen replacement therapy. Female oral contraceptives have been in use for many years, but only recently have we seen studies regarding hormone contraceptive agents in men. " Dr. Dana Ohl, from the University of Michigan, stated at the onset of his lecture on Androgen Therapy in men.
Current polls indicating use of testosterone replacement, illegally by the following :
96% Professional Football Players
80-99% Male Body Builders
11% High School Football Players
6.6% High School Senior Males
The prescription and use of steroids is legal in the United States. The issue is clouded by the Anabolic Steroid Control Act of 1990, which criminalizes sale and possession of any anabolic steroid intended for non-medical use. Misuse of steroids in the sports world has led to stigmatization of their legitimate medical uses; however, some care must nonetheless be exercised in prescribing steroids. The best protection for a physician is to carefully document symptoms and test results and not to over prescribe any replacement therapy.
Black market worth $300-400 million annually. Half are counterfeit. Most said to come from Mexico. Labels often claim illegal importation despite local manufacture. Purity is questionable and users sharing needles run risk of hepatitis, HIV infection and subsequent AIDS, abscesses, cellulitis and death. (6) Potential steroid users are further advised that buying a known counterfeit steroid is a felony, as is buying a non-FDA approved steroid.
Testosterone has been found to inhibit clot formation by decreasing fibrinogen and hardening of the arteries by increasing HDL and decreasing serum triglycerides. (4) It also strengthens muscles beyond normal limits and testosterone is the androgen of greatest concentration in cardiac tissues. Testosterone can make heart muscle more resistant to death during ischemia through improved maintenance of cardiac output as well as decreasing the clotting mechanism. These advantages of testosterone replacement are also associated with a general feeling of well-being, greater strength and return of libido.
The anabolic effects of steroids are those that have a direct effect on the production of muscle mass. There is an increase in muscular strength and recovery from injury or stress. Androgenic effects of steroids include the development or increase of facial hair, the deepening of the voice, stimulation of sebaceous glands and some as yet ill-defined effects on brain tissue.
Anabolic/androgenic steroids, in the presence of an adequate diet, can contribute to increases in body weight in the lean mass compartment through the activation of protein metabolism. The gains in muscular strength achieved through high intensity exercise and proper diet can be increased by the use of anabolic/androgenic steroids in some individuals.
Dangers of Anabolic-Androgenic Steroid Use:
1.Kidney Disease
2.Serum LDLC Increase, HDLC Decrease
3.Hypertension
4.Cardiovascular Disease
5.Stunted Growth
6.Depression
7.Aggression
8.Acne
9.Male Pattern Baldness
10.Gallstones
11.In Male- Testicular Atrophy, Decreased Sperm Production, Gynecomastia
12.In Female- Hypertrophy of Clitoris, Facial Hair, Deepening of Voice
13.Peliosis Hepatitis- blood-filled cysts in liver
14.Cholestatic Jaundice
There are health problems in aging men associated with testosterone administration. Enlargement of the prostate, accelerated progression of undiagnosed prostate cancer, increased hematocrit and a variety of liver lesions can occur. Administering testosterone by intramuscular injection tends to avoid the liver toxicity seen with oral preparations. Administration of testosterone cypionate reduced HDL and synthetic androgen also increase total serum cholesterol. Synthetic androgens are not preferable to preparations of testosterone itself.
Natural vs. Synthetic Testosterone:
Natural testosterone has been available since 1938. Most of the anabolic (tissue building) steroids are synthetic analogs of natural Testosterone, the male hormone. Usually they are taken orally in large quantities which are dangerous and can cause serious liver diseases as well as organ failure. Examples of "roids" such as stanazolol, Winstrol or Android( methyltestosterone), are used by bodybuilders. Injections of nandrolone deconate, or Durabolin, have been available in the gyms of America for over ten years.
These anabolic (tissue building) hormones cause increased incorporation of new amino acids into tissue. This increased protein synthesis, results in growth or hypertrophy of the muscle. Injectable synthetic steroids both androgenic:
Testosterone Esters for Medical Use:
Because testosterone is rapidly metabolized by liver if taken orally or by IM injection, esters, which are more lipid soluble, are produced and injected in a peanut oil base.
A) Testosterone Propionate, is short acting, half-life of 3-6hrs.
B) Testosterone Cypionate (Depo-Testosterone, Virilon IM)
C) Testosterone Enanthate (Delatestryl, Testaval)
One injection can maintain normal serum levels of testosterone for 10-14 days. When used as a replacement, no apparent side effects. Nandrolone deconate is a synthetic testosterone , which transforms to produce both high levels of testosterone and more anabolic steroids. This results in transformation to excess estradiol which can cause gynecomastia (breast enlargement) in men. Testosterone’s action on the muscles has been observed by young male athletes who try to bulk up and recover faster.
Medical uses of anabolic include CRF patients to stimulate red blood cell production. Prevention of angioneurotic edema. Stimulation of protein synthesis (burns, trauma, cancer, AIDS) Men: Congenital Micropenis, Hypogonadism, Impotence, Sexual Libido
Women: Osteoporosis and Endometriosis, Fibrocystic Breast Disease and Breast Cancer.
Children: Stimulate linear bone growth and speeds up growth of secondary sexual characteristics, eg. penile growth and pubic and axillary hair.
Oral Androgens:
Oral androgens are not metabolized into testosterone but act directly on androgen receptors. Because they cannot be bioconverted into DHT or estradiol, they are not as biologically active. All androgens appear to act on same receptors, but tissue sites vary in absorption and metabolism. Oral androgens are used medically for those patients with bleeding disorders or intolerant of injections.
A) Methyltestosterone (Android, Metandren, Oreton methyl, Testred, Virilon)
B) Fluoxymesterone (Halotestin)
C) Danazol (Danacrine)
D) Stanozolol (Stromba, Winstal) Approved for veterinary use only in US
Testosterone Patches and a new alternative:
Natural Testosterone can be used safely in large doses by men who are deficient . Physiologic doses present no apparent health risks. A novel method of administration through a skin delivery system is now available pharmaceutically. (2) Testoderm© is a patch delivery system of natural testosterone. It delivers 4-6mg of testosterone daily and is applied to the shaved scrotum. Androderm® is a very similar preparation which can be applied anywhere. To mimic the normal pattern as much as possible, the higher levels of testosterone occur early in the morning. Androderm patches are applied each morning and result in a surge of hormone within a few hours of application.
Self-administration by this technique is safe but awkward. For hormone replacement in men, a new dihydroxytestosterone gel is being developed by Proctor and Gamble (7) and a natural testosterone cream, ** in rapid absorption polymers has been developed in various strengths up to 100mg (5). Testosterone pellets are also available for hormone replacement in men. Even more reliable , testosterone pellets , contain 25mg of a timed release testosterone ; they can be inserted beneath the skin to deliver testosterone over 4-months in a simple office procedure. (6). All the hormone creams are prescription items which need to be applied twice daily to maintain their 12 hour duration of action. The hormone testosterone is naturally derived from a food source, a Mexican yam , and is identical to that hormone secreted by the testicles.
Why See the Doctor for a Cream?
Side effects of any anabolic steroid depend on the extent to which receptors on target cells are stimulated. There are receptors on sebaceous glands, hair follicles, and muscle tissue and brain tissue. The side effects would then be increased acne, increased body hair growth and increased male pattern baldness, and increased muscle mass. Physicians are well advised to monitor liver function, even if oral steroids are not being used, and to withdraw the hormone or decrease the dosage in such cases.
It does not take much hormone to exceed the recommended physiologic dosage. Monitoring by a physician and regular blood tests are important to get the ideal level for each man. The longer lasting injectable preparations are synthetic steroid supplements and should be delivered intramuscularly by injection under physician supervision. These synthetic products do have various potentially dangerous side effects. Most of the effects are related to liver toxicity from excessive doses. Testosterone has a very large safety margin. Direct toxicity is unknown in men, however in women testosterone does cause masculinization and facial hair growth. Due to the fact that testosterone can be made from progesterone in the female, it has been used successfully as a female sexual stimulant in tiny doses, for women with decreased sex drive due to menopause.
A study is now underway by The Preventive Medicine Clinic of Monterey using the testosterone 10% rapidly absorbing cream. The testosterone cream is a prescription item and requires an early morning blood test to check the serum hormone levels before starting on the hormone therapy. (5) It is also recommended that the PSA (prostate surface antigen) and a DRE ( digital rectal exam) be done prior to hormone treatments of any kind to rule out an occult or hidden cancer.
References:
1. Low Serum Testosterone: a Cardiovascular Risk in Elderly Men. Conrad Swartz, Geriatric Medicine today/Vol 7. No 12/Dec. 1988.
2. Transdermal testosterone Substitution Therapy for male hypogonadism. Bals-Pratsch,M, Yoo YD, Knuth VA, Nieschlag E , 1986 . Lancet 4/943-946.
3. Transdermal delivery of Testosterone. Findlay JC, Place V, Snyder PJ, 1989. J. Clinical Endocrinolology Metab. 64; 266-268.
4. Berkow, Robert, MD, Editor, The Merck Manual of Diagnosis and Therapy, Fifteenth Edition, Merck Sharp & Dohme Research Laboratories, Rahway, NJ 1987
5. Morning erections and testosterone cream. A Clinical study in men with erectile dysfunction. Self published, Abraham H. Kryger, DMD, MD.
6. Bower, Bruce, "Pumped Up and Strung Out", Science News, Vol.140, No. 2, July 13, 1991
7. Barnhart, Edward R., Publisher, Physicians' Desk Reference, 45th Edition, Medical Economics Data, Oradell, NJ 1991
8. Erinoff, Lynda, Editor, and Lin, Geraline C., Editor, National Institute on Drug Abuse Research Monograph Series, Anabolic Steroid Abuse, US Dept. of Health and Human Services, Washington DC, 1990.
9. relating to testosterone use in impotence
10. illegal use of steroids by athletes.