I get messages from many men each week that are searching for answers in the realm of male health, specifically testosterone. There is an undertone of fear around this topic in our society. A lot of us think of male physiology as being very robust, untouchable, but males are not faring well in the current estrogenic sympathetic habitat. More than 80,000 chemicals have been introduced into our environment since WWII, over 2,000 more are added each year, and 870 of these are known endocrine disruptors. Over 220 million pounds of known endocrine disrupting pesticides are used in agriculture each year and 30 of the 37 top used pesticides are antiandrogenic. Remember we are the highest of higher food chain organisms and toxins bioconcentrate as you climb up the food chain; if you think you are safe, even polar bears have been found to be affected by rising tide of antiandrogenic chemicals and birth control excretion.
Dr. John Lee sums it up fairly well with this statement
“Thanks to testing done by a wide array of scientists, we know beyond a doubt that xenobiotics are threatening the survival of many birds, reptiles, and mammals in North America. We would be wise to pay attention to what’s happening with these animals. Miners used to take a canary in a cage down into the mine with them. If the sensitive canary suddenly keeled over and died, they hightailed it out of the mine, knowing the air was poisonous and that soon they would be keeling over. The many animal species more sensitive than humans that are effectively being exterminated by overdoses of xenobiotics could be a large environmental version of the canary in the cage.”
Honestly, I’m f*cking scared. You can feel the storm coming in your bones when you watch the next generation of males. They are mouth breathers attached to their phones late into the evenings running on a constant drip of neon Sonic slushies.
It’s not pretty and we turn it around individually through education and action.
As men how do we know if we are “low”? And what the hell can we do?
In prospective and cross-sectional research those with the lowest testosterone had a 40% higher risk of all cause mortality independent of age, lifestyle, and adiposity
are 2.4 times more likely to be obese
are 3 times more likely to have diabetes
are 2 times more likely to have a stroke or heart attack
are 1.8 times more likely to have high blood pressure
are 1.99 times more likely to suffer from depression.
This data comes with a big IF because maybe in these cases low testosterone is an indicator of overall male health, and thus by separating males by their hormone levels we are automatically segregating the least robust males into their own quartile or tertile?
Yet, if you look at the research for what happens when you give men with low testosterone more testosterone it is overwhelmingly positive with reductions in obesity, increases in insulin sensitivity and lean body mass (even without exercise), reduced depression and heightened motivation, more potent sexual function, and even increased cognitive function (our male frontal lobes very much need testosterone). I won’t comment on the poorly done studies that found increased CVD risk with Testosterone Replacement Therapy (TRT) because they didn’t track a $3.50 measurement like hematocrit. It’s a risk:benefit ratio that has to be assessed and everyone is different.
BUT, we can’t just jump to TRT because giving testosterone without looking at why is not a viable first line solution. Stress knocks down testosterone, acutely and chronically. Iron overload can lower testosterone. Lack of sleep can drop it up to 30% in just a few nights of 5 hours of sleep. Over training can do it and so can dieting. Researchers have induced zinc deficiency and dropped levels by more than 1000ng/dL, nearly into the diagnosable low T range. Something called a variocele (enlargment of the plexus of veins that drain the testicles) can also lower testosterone. You can also have concussions or brain tumors which can damage or infringe on the pituitary and hypothalamus which will knock down the signal to the testes from the brain. Then there are genetic diseases that can result in lower testosterone values. These aspects need to be discussed and tested and in the wide variety of experiences they are not.
Putting a man on Testosterone Replacement Therapy (TRT) should not be an In and Out Burger type decision. I’ll have a large fry and a side of Testosterone Cypionate. Men should be informed and educated. They should have to try everything they can to get their levels up naturally before being able to decide if TRT is the next step. This is not what happens because of lack of time and a need to make money. Hormone doctors don’t make a lot of $$$ (comparatively to other specialties) so they have quick appointments and in turn make quick decisions based on numbers. Additionally, most MDs are not qualified to speak about anything other than compartmentalized hormone physiology. They don’t know enough about exercise, sleep, or stress physiology and definitely not enough about nutrition, and sometimes they don’t know they don’t know which is more dangerous. These docs can also make money off prescribing testosterone which I think is questionable morally given that TRT is potentially an EFT forever ever and sleep makes them zero dollars (unless they need a CPAP) and is much harder to manage.
Interestingly, the Journal of Clinical Endocrinology published this statement in 2007, “Lifestyle measures should attempt to raise testosterone before hormone replacement therapy.” And I still get men almost on a weekly basis who have been put on some form of TRT without any discussion of sleep, stress, nutrition, or life. It’s just embarrassing and ignorant. And if you didn’t get to the root of the problem, the guy may feel amazing for 6 months on TRT, but then he drops off a cliff and feels like shit…again. And then they get out that hammer because he most need more.
“Tell the truth.”
-Dr. Bennet Omalu
Now what is the line in the sand that quantifies low? Labcorp has their number set at 348 ng/dL, CPL 292 ng/dL, and Quest an abysmal 250 ng/dL. But some of the studies from above have had lower grouping that had a cut off at 450 ng/dL. MDs work inside pathologies and standard of cares so they generally need to see a low number before they slap someone on the Jack. Yet, some have odd work arounds for this with liability waivers and will put men on testosterone really early based on near low levels. I have had docs tell me (not knowing who I was),“Yea we have a few teenagers on Testosterone. It’s an epidemic.” Yea it f*cking is, but now you have hijacked the pulsatile nature of his man juice forever without even attempting strategies like zinc supplementation or ummm sleeping.
When I think of hormones, low is lower than you are supposed to be and everyone is likely different. Let’s take my brother for instance. The guy is like Gaston. When we were in high school it was annoying how often little twerps said stuff like, “they probably put steroids in your baby milk.” I wanted to punch them, he normally held me back and just half smiled, but when football practice started they shut up quick. No the guy isn’t on the gear, he is just a f*cking specimen and fills up a XXL t-shirt no problem. So we can guess that his baseline testosterone levels are robust (or maybe he has sensitive receptors) let’s say over 1,000 ng/dL. Now if I try to put him in a schmedium shirt say 525 ng/dL he is not going to be happy and he shouldn’t.
Well life can sure as hell squeeze you into that schmedium, as after 30 testosterone in our current environment falls .4-2.6% per year and sex hormone binding globulin (SHBG) rises by about 2% per year. I will leave Leydig cell physiology for another time. Thus, the greatest gift I think any of us older males can give to the next generation of men is getting really early values so we know baselines. I have a handful of clients 20 and younger and I make sure to let them know how grateful they should be, even if it makes me sound like a civil war veteran.
Now before you go around asking everyone how much they bench press and how high their T is know that no difference in testosterone (both free and total) was seen between top-class athletes and untrained controls and that when we measure testosterone in the serum we are only looking at production from the testicles which are signaled from the brain. We also have transport (i.e. SHBG and albumin(, receptor sensitivity (which we can’t measure yet), and disposal/conversion.
I run serum measures for production and transport and then sometimes urine measures to get a look at disposal. Then regardless of numbers we dial in the fundamentals and see what happens.
Now what if everything isn’t all daytime PBS and lifestyle changes and functional med principles don’t work? Well we need to have a conversation if anything was left on the table. As well as, are there more functional tests we can run to take a deeper look and are there options inside the conventional medicine realm other than TRT?
The answer to those questions is a resounding YES. There are oodles of tests and there are prescription drugs like Clomid, Armidex, and LH analogs that can be used to investigate for primary, secondary, or tertiary hypogonadism. Yet, no one man is the same based on where they are in their life and what they want to do AND that is why this has to be a conversation that lasts longer than 7 minutes.
We also have to begin to unpack our governmental baseball induced hate of anything steroids. These men are not less. They are not going supraphysiological. They are not broken. They are your fathers, husbands, and hopefully not sons. They just need some help because we are living longer and our environment has been changed forever by those same governments. Should a man on TRT be able to compete in the Olympics? Probably not. Should they be able to pick up their kids with a smile on their face knowing they did everything in their power to beat a deck of cards stacked against them? F*ck yes. Should they feel guilty because they take a shot a few times a week? Not for a second because this runs deeper than any injection and we don’t have time for guilt.
*If you want to fact check this article, please do so. I have over 300 resources in my End Note on testosterone and any book on male health – I own it. I wrote this off the cuff this morning because this is why I wake up. To help men understand and navigate this terrain.
**The book on male health is almost done and my goal is to have it out by mid-September. It is not like any other book out there. It is not a functional med textbook. It is a story. I want men to want to want to read it and not be able to put it down. I have done my best to hide a lot science in a veil of suspense and character development. We shall see.