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Functional Approach to Men's Health

Of the many health issues that are important to men, most result from hormone imbalance.  Focus on individual symptoms, such as hair loss, erectile dysfunction and prostatic enlargement tend to divert attention to the underlying pathology that directly, or indirectly results in each of these three, prevalent problems.


Estrogen

As women age past early adulthood, estrogen levels tend to decrease.  The symptoms that result are well known to most medical practitioners.  In men, however, estrogen levels tend to increase with age.  Around the age of 40 years, the total estrogen level in an average male equals or exceeds the female of the same age.  After this middle-aged crossing point, male estrogen levels tend to significantly exceed those in females.  It is the increase in estrogen level that tends to cause many of the age-related medical complaints in men, particularly those related to prostatic enlargement and erectile dysfunction. 


Testosterone

Testosterone levels peak, in men and women, in early adulthood, and in both men and women, testosterone levels decrease, linearly, with age.  The testosterone level in a man of 50 years of age will be approximately 50% of what that level was when the man was 25 years of age.  


DHEA

Dihydroepinandosterone (DHEA) is the most prevalent hormone in human physiology.  Sometimes referred to as the “fountain of youth hormone,” DHEA is a precursor to progesterone, testosterone and estradiol.  DHEA levels predictably drop with age, but in a significant number of persons, these levels can fall to ‘levels of detection,’ and below.  That is, DHEA can be observed to drop off the chart, entirely.  Low levels of DHEA has been identified as factor in depressive illness, low levels result in loss of libido in men and women, and low levels of this  hormone are related to the development of dementia. 


The Ratio Effect

Steroidal hormones act to trigger genetic switches in cell nuclei.  The effector sites at the cell nucleus most often involve multiple hormones, some stimulatory, some inhibitory.  The ratio of these hormones, relative to each other, triggers cellular events.  That is, the ratio of testosterone to estrogen, or estrogen to progesterone determines cellular effect.  It is for this reason that the ‘level’ of the hormone is only significant in relation to the other hormones that effect the same genetic trigger. In short, it is the testosterone to estrogen ratio that will indicate the state of balance.  Other hormones, such as pregnenolone, androstendione, thyroxin, and cortisol are important, and attention to these is important, as well.


Hormone Replacement

Restoration of hormone balance is the goal of therapeutic intervention, and this intervention takes place on several levels.  Replacement of depleted hormones must reflect diurnal and seasonal cycles.  Testosterone, for example, normally peaks in the very early morning hours, and drops as the day progresses.  Testosterone replacement is best accomplished with daily application, transdermally.  When testosterone is used, it should be administered so that it peaks in the morning and drops, as occurs in nature.  Sustained release patches are not as physiologically satisfactory as an immediate release cream.  Consideration must be given as to where the cream is applied, as well, so as to avoid lipid tissues that chemically convert testosterone to estradiol.  Further, these testosterone creams can be given in such a way as to diminish this testosterone to estradiol conversion, through the skin. 

When given in an unthoughtful way, testosterone will convert to estradiol, and then the patient will see worsened gynecomastia, hair loss, axial obesity and worsening of the erectile complaints.  This is seen most commonly in athletes, weight lifters, and amateur athletes that use intramuscular testosterone.  The weekly I.M. bolus results in very high estrogen levels and systemic problems invariably follow.

DHEA is relatively inexpensive and easily administered.  Diurnal variations in DHEA are not as pronounced as with testosterone, so timing is not as tricky.  DHEA can be administered orally.  The main issue with DHEA is absorption due to lipid solubility, and liver enzyme induction when given in high doses.  These pitfalls are avoided by administering the DHEA simultaneously with a fish oil capsule.


Non-prescription Intervention

Reduction in serum estrogen levels is possible through the use of inexpensive, commonly available supplements.  Testosterone levels can be increased with the proper use of Saw Palmetto, indole-3-carbinol, and zinc.  Estrogen levels can be decreased with the proper use of silymarin, fiber, and D-glucaric acid. Pharmaceutical-grade products are available, at reasonable cost to the patient.

Quality is never guaranteed by high price, but one rarely gets high quality without some expenditure.  It is important for the practitioner to understand how to guide the patient through the maze of available OTC products, some of which are of exceptional quality, and some are of little use, at all. Further, timing of when to take the medicines and supplements is essential to successful treatment.

Improvement in erectile dysfunction, nocturia and depression can be seen in as little as 2-3 weeks.  Restoration of hair growth can be seen in 4-6 weeks.  Reversal of gynecomastia and axial obesity can take 6-12 months. 


David S. Klein, MD, FACA, FACPM.

This article is intended for general information purposes only and is not a substitute for specific medical advice. Please consult your health care provider to determine how this information pertains to your specific medical situation.