How to Restore Testosterone in Low-T Men
What is Testosterone?
A large part of my practice consists of treating men and women with hormonal deficiencies, whether testosterone in men or usually a combination of low estrogen, progesterone, and testosterone in women. DHEA and other hormones such as T4 and T3, cortisol, or growth hormone can be low in either gender. I will focus here on low testosterone or "Low T" in men-what causes it, what are the options for treating it, and what sort of results can one realistically expect.
Testosterone is the hormone needed to change a boy to a man and then to maintain a healthy male metabolism and physique; it is made in the testicles due to the influence of a brain hormone called LH.
Testosterone levels peak during puberty and young manhood at about 1000-1200 ng/dl. From that point on, men experience a slow decline in levels to about 100-200 on average in men who reach their 80s or 90s.
Why do Testosterone levels decline?
Many factors are at play here, some well understood and others less so. First, there is a slow decline in the number and activity of the testicular cells that make testosterone, the Leydig Cells. Without them, testosterone doesn't get made. This can be a result of normal ageing but can be accelerated by testicular damage from infections (mumps), poor nutrition (living on fast food and pizza), orchitis, environmental toxins (including prescription medications and plastics, pesticides, chemicals and preservatives in food) and heavy metals, heat (tight underwear), physical damage (those kicks to the groin during football games), radiation exposure, and anabolic steroid use which leads to atrophy.
Alternatively, the brain may make less of a testicular-stimulating hormone called LH. There are many causes for this including stress, pituitary adenomas, sarcoidosis, iron-overload, heavy metal damage to the pituitary, autoimmune disease of the pituitary or hypothalamus, or excess estrogen exposure.
Symptoms of Low Testosterone
The end result is that a man feels the symptoms of low testosterone. Obviously Low-T is associated with low libido and erectile dysfunction. But did you know that fatigue, increased belly fat, falling asleep after eating, poor mental performance (confusion, indecision, poor memory), loss of muscle mass, bone weakness (osteoporosis), high blood sugar, and an increased rate of prostate cancer and heart disease are also associated with Low-T. Yes, these last two are associated with men who have low testosterone, not high. Low T is associated with a higher overall mortality rate in men.
Can Low-T be treated?
The first thing I do at my office consult with you is to try to find out the cause and reverse it, if possible.
A clean, hopefully organic, paleolithic diet is a must. Without good nutrition, the body can't function properly-and that includes making testosterone. Cut out the junk food.
Lower stress levels; stress reduces LH and thus testosterone. Learn to relax, meditate, play sports, exercise, get enough sleep, have more sex, and perhaps change your job-whatever it takes to lower that chronic stress level. If you feel more libido on vacation than in your day to day life, then this may be your problem.
Then we move onto detoxification, getting those pesticides and other chemicals out of the body through many avenues. We can check for heavy metal toxicity and eliminate them if present.
Is there an autoimmune disease attacking the pituitary/hypothalamus? I try to get it under control. Is testosterone being converted to estradiol? Estradiol shuts down testosterone production, so we regulate its production to low levels. When all that has been optimized, we then examine whether there is still a deficiency in testosterone and what level of LH is being produced. Usually I do all these things simultaneously.
Normally, when there is not enough testosterone being made, this is sensed by the pituitary in the brain, which makes more LH to stimulate the testicles. When LH is high and T is low, we say the problem is in the testicles. After the above measures have been taken, I usually have to administer testosterone as the testicles simply can't make enough due to damage. If LH is low and testosterone is low, then the problem may actually be in the brain, since the pituitary is not making LH to stimulate the testicles. In that case, I might use Clomid, HCG, aromatase inhibitors. I always look at the levels of estradiol. Estradiol turns off LH production. Many overweight men make estradiol in their fat cells from the limited amount of testosterone they produce; this then shuts down testosterone production even more. I block this process by various means: anastrozole, zinc, chrysin, even metformin, melatonin or progesterone can help. Weight (fat) loss is critical: getting rid of the fat reduces aromatization and lowers estrogen.
Testosterone Replacement Methods
Let's say a man needs actual testosterone. What is the best way to replace it? There are 4 real options:
Testosterone Pellet Therapy
In my opinion, this is the best way to replace testosterone (in men or women). The levels in the blood reach a high level, around 1000-1200 and can be adjusted easily up or down by adjusting the number of pellets inserted. They are inserted on the hip or flank (love handle) area in a minor office procedure which is painless and takes 10 minutes, and last about 4 months. The cost is a bit higher, but averaged out over 4 months, it costs no more than a Starbucks coffee per day.
Men like this approach as they "feel" good again: great libido, erectile function, energy, mental focus, better performance in the gym, fat loss, and overall vigor. The testosterone and estradiol levels are easy to monitor by simple blood testing.
The downsides are the slightly higher cost, the need for a minor surgical procedure and 5-7 day healing time during which you can't do vigorous exercise, and the slight potential risk of a skin infection (very rare).
Hormone Gels or Creams
There are two brand name products available: Androgel and Testim. I prefer to have gels compounded by a specialty pharmacy as they have better absorption in a smaller volume than these products and are usually cheaper for the patient. However, it may be cheaper to buy the brand name product, depending on your insurance coverage co-pay.
Compounded testosterone only costs about $40/month. Many men find the gels satisfactory if they have only slightly low levels, but many don't get full return of that youthful vigor and sexual performance with creams and gels.
Men who have tried gels and pellets, usually prefer the pellets. The downside is that the gel will spread all over your home and workplace so any women in your life will be exposed and show higher than normal testosterone levels. For this reason, men with daughters or wives often prefer pellets or injections. It has to be applied to hairless skin, so this can be a problem for hairy men. Travel is convenient and application is painless.
WARNING: Testosterone applied to the skin will turn into DHT, the hormone that makes your prostate enlarge and the hair on your head fall out! For this reason, I encourage either pellets or injections as a first approach. If a man wants to use a skin cream or gel, we MUST monitor levels of DHT and keep them in the low normal range with medication to prevent these serious adverse effects. If your doctor is not doing this, find a more knowledgeable doctor!
Testosterone injections are a tried and true method that achieves satisfactory blood levels without contaminating others and injected testosterone tends not to convert to the DHT hormone.
The blood levels are not steady as with pellets, but oscillate up and down with each injection. This affects how men feel-they may feel overly stimulated after a shot and then feel fatigue and lack of libido when the testosterone starts to wear off.
Also, you have to be willing to inject yourself with a syringe. Injection sites can become infected. You can be allergic to the injected oil.
Travel is an issue; many men don't wish to explain to the TSA why they are carrying syringes and controlled drugs through airports, it is easily forgotten and left at home. Gels and pellets are easier to travel with.
Cost can be higher than gels but slightly less than pellets.
Athletes often prefer injections as they have no "down time" as with pellets. Estradiol levels, hematocrit, PSA, and DHT MUST be monitored and controlled carefully with injection therapy.
There is a testosterone patch available but, having tried it myself I wouldn't recommend it. It is large and sticks so tightly to the skin that removing it causes a skin burn. One ends up with welts all over one's body. It has to be applied to hairless skin, so you have to shave your body hair. Not a great solution. None of my patients use this system.
Kisspeptin-10 is a peptide that triggers the production of LH and FSH when injected. It is normally found in high levels in teenagers and is the trigger to start puberty. It can be used to boost natural testosterone production in older men and to reverse testicular atrophy caused by testosterone use.
HCG and Clomid
These are drugs that either mimic LH (HCG) or cause the pituitary to secrete more LH (Clomid). LH causes the testicle to make more testosterone if the testicle is healthy. They can be useful to preserve fertility or testicular size in men on TRT. Some younger men can use these instead of testosterone and make enough testosterone with these drugs alone. Some men combine HCG with testosterone pellets or injections as they feel it "smoothes out" the testosterone effect and maintains testicular size and fertility.
Rescue of testosterone production after anabolic steroid abuse
Unfortunately, anabolic steroid use often permanently shuts off testosterone production. However, if one is treated soon enough after a cycle, it is sometimes possible to restore normal testicular function and testosterone production.
We use a combination of aromatase inhibitors, Clomid, HCG, or Kisspeptin-10. The success rate is variable but making one's own T is always a better option than being dependent on T replacement for life, so it's worth a try in my opinion.
What about herbs and products advertised on TV? They usually contain an herb called yohimbe and another called tribulus. These herbs may slightly improve libido and perhaps slightly increase free testosterone levels but not to the levels needed by men who are truly hormonally deficient. And they do nothing about fixing the root causes or treating excess estradiol. I don't recommend them. Many of my patients have tried these products without any real benefit.
What can you expect at your First Visit?
Your first visit with us will involve meeting with Dr. Kaye for 90 minutes. During that visit, he will review and discuss with you the medical information you provided in our intake forms. He will check your vital signs and do a brief exam, and check your body composition. We will then look at all the data, combined with your physical exam findings and discuss healthy diet and lifestyle and options for treatment. Usually we will need to do some blood testing and this will be ordered at your visit. You will have the opportunity to meet with our nutritionist to start a weight-loss program or further discuss diet.
Many of our patients have co-existing health issues and we put all the pieces together and come up with a plan of treatment. We want to prioritize what YOU feel is most important. For some men it may be an improved sense of energy and motivation, a better libido, better erections. Others may be more focused on weight loss and prevention of heart disease or diabetes. Be assured, we will address all your concerns relating to hormones and even address your non-hormonal issues such as IBS, food and environmental allergies, thyroid and adrenal disorders, chronic fatigue/fibromyalgia, autoimmune diseases, cholesterol and heart-disease prevention, nutritional deficiencies and supplements, and mood disorders.
All BHRT prescriptions are individualized for each patient and we monitor your symptoms and blood testing carefully to make sure you are taking exactly the right dose for you--this is not a one size fits all approach.
For men with Erectile Dysfunction who do not get full improvement after diet and hormones are optimal, we offer two patented therapies: Gainswave and the P-Shot. These treatments have up to 90% rate of significantly improving erection hardness, duration, and sensitivity.
Request Your Appointment!
If you have questions or think you may be a candidate for one of these treatment modalities or your current physician doesn't seem quite "up to date" on these issues, feel free to call my office and I'll try to assist you. To make an appointment, please call 781.933.4200 or fill out our online contact form below.