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Welcome to AIM For Health: Root-Cause Conversations with Dr. James Biddle. All content from the conversations in this podcast are created and published for informational purposes only. This is not intended to be a substitute for professional medical advice and should not be relied on for personal medical decisions. Always seek the guidance of your doctor with any questions you have regarding a medical condition.
Hi, welcome back. This is “Ask Dr. Jim Bob”. I am Dr. James Robert Biddle, I am a medical doctor, I am board-certified in internal medicine, and I have been running Asheville Integrative Medicine for 23 years now, and to help us today is our ever-present new-patient coordinator, Joy Lambert. Hi Joy!
Hi Dr. Biddle – Hi everyone!
Today we are talking about –
Today we are talking about men!
We’re talking about men.
Men at work?
No – men and their hormones.
Oh, their hormones.
I know it’s a myth, so I thought we would start off by busting that myth. Do men have hormones?
Men have lots of hormones. The big difference is men’s hormones are steady-state rather than cycling, which is why there is that myth. So women’s hormones change through the month as they go through their cycles, once they are between the ages of like 13 and 50. But men have testosterone every day of the year which is their blessing and their curse.
Well, let’s learn more about that.
Right. So men do go through male menopause and we call that andropause. And the big difference is that women go through menopause predictably, somewhere between age 45 and 55 for most women with the average around age 50-52, although I have known women who have gone to age 62 before they really go into menopause.
Wow – that late!
Yes, it’s amazing.
But, they are going to go through menopause because evolutionarily, if they get pregnant after age 60 they are going to die during childbirth probably, and so the ovaries shut down and they are not going to get pregnant, so that is a way to keep them alive longer so they can contribute to their community and their grandchildren and children and great-grandchildren, and all that.
So there’s a reason why women go through menopause.
There’s a reason why women go through menopause, but men never get pregnant, so they don’t need to go through andropause. At age 50 5% of guys are low in testosterone and at age 70 it is 70% in America. So there is a very steep curve between 50 and 70, but if you can, be like Jack LaLane and be 80 and still have normal testosterone and good muscle mass and all that.
So when you start to lose your testosterone in men you get symptoms and those symptoms include fatigue, apathy, grumpy old man syndrome,
That never happens…
Mood instability, erectile dysfunction, lack of muscle mass, putting on more fat mass – you just lose your get up and go. It’s also associated with some serious stuff like increasing risk of diabetes, heart disease, and dementia. So it is one of the major predictors of who ends up in a nursing home and who doesn’t.
Their testosterone levels?
Their testosterone levels.
Well I am excited to learn more about this. So it sounds like men don’t have to go through andropause but if those symptoms are presenting themselves, that’s an indicator that something is not in balance.
Yes, they may be going through it.
All right, ok. Well, my first question is about testosterone. Does testosterone drive men’s hormones, all of their hormones, or do their other hormones or glands drive the testosterone – how does that work?
Well, testosterone has a precursor called DHEA and DHEA is made both by the testicles and the adrenal glands, and we can take DHEA to raise the testosterone. The problem is the DHEA can also turn into estrogen. If you are low in something, often it is because there is a pathway that is blocked, so for example if I am low in testosterone and I take DHEA, I might end up with more estrogen than more testosterone. So I am not a big fan of using precursors for that reason. But, yes, testosterone is really important and we don’t want it to get low. All the other hormones, just like in women, thyroid hormone, adrenal hormones – they all play a concert, but men have a lot less thyroid problems than women do, they in general have a little bit less adrenal problems than women do, and we talked about all those separately.
So men are generally more stable, but they are susceptible to suppression by excessive cortisol release.
So when we get these surges of cortisol, it gives a feedback from our pituitary which kind of shuts down the signal to the testicles. So common causes of excess cortisol are psychological stress.
Everything from financial stress to sitting in traffic to chronic anger, just worry about what is happening politically, financially, ecologically – all these are stressors, but then personal stressors like blood sugar rollercoaster, blood sugar going up and down.
And untreated sleep apnea, so if you are not treating your sleep apnea and every time your airway occludes which can be 15-45 times an hour, you get a cortisol spike and a stress response, and down goes your testosterone.
Well that’s not good!
That’s not good.
And that is part of why we always want to look at underlying sleep apnea and there is a previous podcast about that everyone, so if you haven’t listened to that one, please go do so because it is very important!
Yes, it’s a huge epidemic.
So you’re talking about declining testosterone amounts. Let’s talk some about how do we measure that both in the conventional medical field and then what are we looking at.
Right. So blood tests are the usual, if you want to be really accurate you get a morning blood test because men’s testosterone is higher in the morning. If you are more sensitive you get an afternoon testosterone, you know, if you want to see how low it’s going.
Oh ok, that makes sense.
The problem with the reference ranges is they are too wide. They will go from 250 to like 1200 and the next problem is men don’t have a baseline from when they were young and healthy. So let’s say a guy comes in and he is 60 years old, and you check his testosterone and it is 300. Well that’s normal, doctor says it’s normal. But if you would have had a baseline at 45 you would have known that his baseline testosterone was 900 when he was closer to his prime.
That’s a significant drop.
It’s not even a third of what you were just 15 years earlier, but the doctor is telling you you’re normal, that’s not your issue.
I bet that doesn’t feel normal.
It doesn’t feel normal at all. So there is a difference between what is kind of average and what is good and healthy. We are looking at much tighter reference ranges when it comes to interpretation. We can also do saliva testosterone, you can do a urine testosterone, we can do a complete panel that looks at testosterone and adrenal hormones and all the estrogens called a DUTCH test that is a urine paper blot so it is really easy to send in. You don’t have to collect a big jug of urine.
No, you just get to pee on things.
Right, you just get to pee on the paper. So there are lots of different ways to look at it. When you are talking about once you are on replacement therapy, you need a more standardized way. Then the urine and the saliva are not so good and you really need to use the blood tests to be standardized.
So let’s talk about conventional replacement therapy and then things that we can do.
Well, so one of the things that I think doctors do wrong is as soon as a guy’s testosterone is low they put him on testosterone shots or patches or creams. And the problem with that is once you start testosterone you are going to be on it for life because you get a negative feedback loop inhibition. Your pituitary stops making LH, your testicles shrink and you stop making your own testosterone. If you now stop your testosterone replacement therapy you are worse than you were when you started. Which is OK if you’re 70 or 75 right? But if you are 45 years old, now you’re looking at 40 years of testosterone shots in front of you.
No thank you!
Yes. So what we are looking at is what causes the low testosterone and often just reversing that can cure the problem. Iron overload is another common cause, unrecognized.
Of low testosterone?
Yes, iron insiderates into organs like the pancreas and the liver and increases diabetes, it insiderates into the heart, increases heart disease. But it insiderates into the testicles and turns them off. It basically rusts them. You have rusted testicles.
Oh no – that’s terrible!
Terrible! I can’t imagine walking around – that sounds like it would be a big chaffing problem. But anyway, it causes low testosterone. So we can often treat your sleep apnea, lower your iron – you know, we can fix that. And then your testosterone may come back to normal, or we might goose your testicles and get them working again.
And how would we do that?
Well, the first way is to use some herbs. There are a variety of different herbs like Tribulus and horny goat weed, and different things that we have a combination called Men’s Support that has all those in it, and that will work for some guys. If it doesn’t work then we will use fertility drugs. Fertility drugs given to women to get them to pop out more eggs will also goose the testicles. Yes, so the first one is called Clomid or clomiphene.
What does that do?
It’s a pill, a very easy to take pill. We usually give ½ a pill 3 x a week for a cycle of 6-7 weeks, and you actually, guys will report “my testicles are kind of sore, kind of like when I went through puberty”, starting to swell a little bit, and that can double your testosterone level and kind of puts you back through puberty. And then we alternate that with pregnancy hormone called HCG, human chorionic gonadotropin, so that is also used in fertility for women, same sort of thing. And if we go back and forth between those it actually stimulate and re-matures the testicles, not only to start making more testosterone again, but also if they are low in sperm count it can bring that up if they are interested in fertility.
Yes, so that is a way to restore that in men.
Now what sort of time frame would one expect if they are going to go through that sort of rehabilitation?
Pretty quickly. I mean we’ll put them on the Clomid and then check levels at 6 weeks and then switch to the HCG and check levels after another 6 weeks on that, and for some guys one round like that will get them going again if we have reversed the underlying cause. Other guys might need more cycles and then they can take time off and be fine for a while, and maybe they need intermittent cycles. Some guys will need it continuously. But it’s at least not suppressing their system the way testosterone would. So I have had guys on that either continuously or intermittently for a decade for example. And then when they finally get up to 65, 70 years of ages, maybe 75, then I might switch them over to the testosterone shots.
Wow – well that’s very interesting and nice to have that option to not have to have shots every week for the rest of your life.
Yes, so I call that testicular rehabilitation. Now the HCG is a shot, but it’s just a subcutaneous shot 3 x a week, so under the skin, as opposed to the testosterone shots which is an intramuscular shot in the muscle of your thigh, usually once a week, with a little bit deeper needle. So the complications with that process is it can drive up estrogens, so we are very cautious to watch the estrogens and if guys are getting high estrogen we give them a medication called anastrazole or Arimidex is the trade name. That blocks the enzyme that converts testosterone to estrogen. That enzyme is called aromatase and it is in fat cells so the heavier you are the more of that enzyme you have. This medication, the anastrazole, is actually given to women with breast cancer to lower their estrogens.
Oh, I see.
So in women, when you read about side effects, it has terrible side effects of acute menopause, all the symptoms of terrible acute menopause. You know, hot flashes and all that, but in men we are giving a lot lower dose. We are not giving a whole pill a day, we are giving ½ a pill twice a week.
Or maybe 3 x a week if you are a big guy. But that works really well to keep the estrogen down. Now when you go to testosterone replacement therapy, you can use creams to go through the skin, but there are a couple of problems with that. One is the cream may not stay on you.
Right – it can rub off if it isn’t absorbed.
Yes, and especially rub off onto your wife or your girlfriend, and all of a sudden she may be having a lot higher libido, but she may also have a beard, so that can be a problem. It may rub off onto your grandchildren, that can be a real problem, or your guinea pig – I don’t know. The creams are ok but I worry about them not staying on the person we are treating.
Then you have patches and the patches work really well but they can be like $400.00 a month.
Yes, big pharma is really extracting a big price for that, for something that should be like – and even the creams from big pharma are $200 to $400 a month. We can make creams from a compounding pharmacy for about $50.00 a month, you can get that down.
Well, yes, I mean especially if this is going to help prevent men from needing nursing home care later in life, like why wouldn’t you want to do that, or make it accessible.
Sure. But the shots are about $10.00 a month, if you do them yourself. It is really inexpensive to do testosterone shots and we can teach people to do them themselves. So that is what I prefer and you get less transition into the estrogen that way. Because if you put it through the skin it’s going right into the fat cells, so you get more estrogens. So I prefer the shots when we can do it, which is 9 out of 10 times guys can do it, and then the 10th guy just comes in here once a week for the shot and we charge him $20.00 for the shot.
So that is how we get around that. Now there are a couple of complications of testosterone that you have to be aware of. It can make thick blood.
Thick. It stimulates your bone marrow to crank out more red blood cells, so your hemoglobin and hematocrit can go up. Actually one-third of the time in guys. And we have got to keep an eye on that.
Now why don’t you want thicker or higher viscosity blood?
Because you can get clogging of your artery and have a heart attack or a stroke.
Definitely not good!
And that is why there is mixed results on studies giving testosterone in guys with heart disease. The good studies, it shows it decreases heart disease, but the poorly designed studies where they are not taking this into account and following this, they are having this complication of a short-term increase in heart attacks because of the thick blood. But it is very easy when you are checking the testosterone in followup, you just check a blood count, a CBC, and track that. And of course 2 other things that cause thick blood –
Iron overload and sleep apnea.
Because of the low oxygen, right? So we want to be looking at those.
Definitely have to have that whole picture in place for everything to make sense.
Right. And then the other complication is it can turn into estrogens which we talked about, or it can turn into dihydrotestosterone and dihydrotestosterone can make men lose their hair faster if they are prone to that, with male pattern baldness genes. And it can make more enlargement of the prostate gland. Now testosterone itself does not cause enlargement of the prostate and does not cause prostate cancer, but estrogens and DHT do cause that. And if you already have a prostate cancer any testosterone can make it grow faster, so you have to keep an eye on the PSA, the prostate specific antigen, in the bloodstream.
So not only do men have hormones, it’s important to keep an eye on them and to know what’s going on.
That’s right. Because your hormone levels predict physical and mental frailty in men, and there is even one study on early dementia and if guys had low testosterone and you replace it, a lot of early dementia gets reversed.
Yes. I am looking at this study, it was published in 1997 actually, about protecting against Alzheimer’s disease.
Wow. Now these are some, a variety of things that we do in terms of rehabilitation and replacing testosterone. Aren’t there some other things though that may help? or that may play a factor?
Yes. Some of the things, I mean just keeping yourself in good shape, keeping your fat mass down into the appropriate range so you are not obese, exercising regularly and keeping your muscle mass up, because muscle mass is metabolically active, it helps you keep your hormones in shape. So not only does testosterone help you build muscle, but muscle helps you build testosterone. And then cold showers.
Cold showers or cold plunges. So I personally- two years ago my testosterone had dipped a little bit and without doing anything else I just started doing cold showers every day or twice a day, and I raised it by 25%.
Really? Now how, I mean, how cold is cold? I’m going to say that lukewarm is cold, but what is actually cold for therapeutic effect?
I just turn on the cold water, and water comes out of the tap at 55 degrees because that is the temperature of the earth, it is usually 55 to 57 degrees, the water if you are just running cold water. And then I take my shower, and I save a lot of money on hot water. But don’t worry, the women in the house use enough.
I bet you take faster showers now too!
I do. That’s right! And interestingly I have less skin problems because the hot water strips oil out of your skin so you get more dry skin, especially in the winter. So not taking those hot showers is actually good for your skin. And then I have a hot tub and next to my hot tub I have a cold plunge and I have a 100 gallon tank that is two-thirds filled with cold water and after cycles in the hot tub, I get in the cold plunge and I stay there for 20-30 breaths.
Breaths, not minutes.
Not minutes, breaths. So that turns out to be like 3 to 5 minutes usually. And try to actually drop your core temperature a little bit and that has been shown – there is a guy name Wim Hof, and he has popularized this whole thing about cold showers. You can look him up and read about that and how it helps with antiaging and endurance and all sorts of things.
But like I said, you have got to be a man to do it!
It might make you scream like a girl though!
You jump into icy water!
It’s one of the secrets – l scream every time!
Now, you also mentioned before that cold showers can, can’t that be helpful with weight loss? Would that in effect be helpful with your hormone balancing?
It does, because one of the things it does is it turns your white fat into brown fat, and the white fat is completely non-metabolically active, it’s just sitting there doing nothing. But brown fat is kind of like muscles – it’s burning energy, it’s making hormones, it’s helping you metabolically, and it is thought to help your immune system. So this is a big secret about of course how Scandinavian peoples get through their long cold winters right? They do the saunas or hot tubs alternating with the cold plunges, and then they kind of become immune. And here’s a secret especially in the winter when you do something like a sauna or a hot tub. If you just get out all your pores are open and then you lose your heat and you start to shiver and get cold really quickly. But if you end with a cold plunge, then all your pores close and you retain all that heat and I can walk around in the middle of winter with just my towel on for like 5 minutes before I even start to feel the cold. You get nice and dried off and get dressed, and you don’t get cold again because you retain that heat.
Well that’s fascinating!
You want to seal that heat in.
I would have thought you don’t feel the cold because you’re so numb from the cold plunge.
No it’s not that.
Huh, all right. And so if someone wants to try it, does it have to be every day for cold showers in terms of raising testosterone levels?
No. Well, who knows? I don’t think that has been studied well, but I will say the best time to begin taking cold showers is right after a very vigorous workout when you are all hot and sweaty anyway and it feels good.
That makes sense.
And then most people then take their usual showers and then do the last 1 to 1 ½ minutes cold and they can tolerate that, and then gradually just kind of do less and less hot in your showers, but you get to – I am just to the point where I just turn that cold water on, look at it, then take a step forward and stick my face right into it, let out a little bit of air and go ahhh, and then I’m good.
Just take the plunge!
Take the plunge, and it really wakes me up.
So have you seen, you mentioned muscles before, so with muscle mass if someone has lower muscle mass and they do appropriate muscle strength training and they are able to build that – so that alone can help balance or help build testosterone levels?
Yes, that low muscle mass with aging is called sarcopenia.
Yes, penia means not enough and sarco means muscle, red muscle specifically. So yes, that can help.
And then what about food and how that relates to our hormone health and balance? Particularly for men.
Well the most important thing about food is not to be eating hormones. So when you eat nonorganic dairy products, especially concentrated ones like cheese and butter, and cream, those cows that are not raised organically have an estrogen pellet inserted under the skin of their ear so they make more milk, and then we drink that estrogen and that is a big cause of the very steep rises in prostate cancer and breast cancer, but also why our little girls are going through puberty –
It’s supposed to be at 13 to 14 to 15 years of age.
Now it’s 8, 9-
Now it’s 8, 9, 10. Obesity also contributes to that, but a lot of it is the nonorganic dairy products. And then even meats will often be given hormones too, so I think meat and dairy are the most important foods to eat organically if you are going to be eating them. And then soy – soy is problematic. It has phytoestrogens which in some ways are good for women because they are less strong than the other estrogens, so it actually decreases breast cancer risk, but men aren’t supposed to have that much and you can get real problems. There are these interesting studies on babies given soy infant formula and you calculate it out and they are getting like 10 x per body weight more estrogens than postmenopausal hormone replacement therapy, for example. So it is really problematic for men to eat too much soy because of getting all that estrogens. Soy has other problems – if it is not fermented it has enzyme inhibitors which I think we talked about in the nutrition series.
Yes. So generally avoiding soy would be a good idea and at least having hormone-free, antibiotic-free meat and dairy products would be a good start.
Yes. And I think men can eat some soy, as long as it is fermented like tempeh and miso, but organic foods are really important for this particular issue.
All right. On to the next question.
The sensitive topic.
Yes. The thing that no one wants to talk about, but we’re going to go there. And we are going to talk about it.
Let’s talk about ED.
Yes, and what role do hormones play with that?
Well, testosterone is definitely related. If you have no testosterone you’re not going to have the libido and you’re unlikely to have good erections. And having said that, I meet men who are very sensitive to this. If their testosterone gets a little bit low they do have problems, and I also meet men who have very low testosterones and while their libido is down, they are like “Yeah, no problem, I can have erections”. So it’s not the only thing going on there and it varies a lot. But there are at least 4 other causes for erectile dysfunction. So medication side effects is a big one, especially beta blockers, a blood pressure medicine, and some of the psychiatric drugs for depression. Then there’s vascular, if you have clogging of your arteries everywhere else, then you can have clogging of the arteries in your pelvis and you’re not getting blood flow there. And that is a very challenging thing to treat. I have treated men with chelation therapy and gotten improvement in blood flow and reversed that for guys.
It takes about 30-40 IV treatments to achieve that, and then maintenance therapy, so that’s an investment. And then there is nerve damage, and that’s usually diabetics. If you are getting neuropathy in your feet, you’re probably also getting neuropathy in your private parts.
And that’s a big cause of erectile dysfunction, a little bit easier to treat because it does respond to treatments better than the vascular issues for example. The other unusual thing is people who ride bikes for extended periods of time.
I’ve heard about that.
Yes, there’s a little nerve called the pudendal nerve. In medical school we are taught “L-2, 3, and 4 keeps your penis off the floor”. So that’s the lumbar nerves of level 2, 3, and 4 contribute to the pudendal nerve and that gets crunched when you ride a bicycle for long periods of time.
Now is it the configuration of the bike seat itself, or just sitting for long period of time?
It’s the bike seat itself, yes. If you are sitting in a flat chair that doesn’t happen. So that’s why the men’s bikes will have a special design kind of to take the pressure off of that. But it’s still problematic because if you are riding 100 miles, even with a good seat, that can be problematic for sure.
And then psychological. So once men have an unsuccessful attempt, once they have an erectile dysfunction, the next time they go to have sex it is very hard to be relaxed.
And erections are actually a product of your parasympathetic or relaxation response. Ejaculation is a product of the sympathetic or excitatory response.
So you need to relax first before you can be aroused.
You need to relax to be aroused – exactly. And once you’re worried about it then you have a thing called the critical observer that a large part of your psychic energy is spent watching to see if you have an erection rather than enjoying your partner, what’s going on, and that’s not relaxing and it’s not sexy, and you’re not going to have an erection. So I actually train guys in how to gag the critical observer and it is a process called sensate focus.
Yes, you focus on your senses. You get your brain so busy in the present moment that it doesn’t have space to wonder about whether you have an erection or not. So you use your eyes and then when you find your mind wandering then you use your ears, and you listen to your partner. You use your nose and you smell your partner, use your mouth and you taste your partner. You use your skin and you feel, and you just keep yourself immersed in your senses which is one technique for remaining in the present moment and it takes you out of your head and into your body.
That’s good to know.
That’s the basic exercise for overcoming and with a little help from the medications like Viagra or Cialis. So that is one of the best uses for those is giving men a little confidence because then they are less reliant upon what is going on in their head and they are going to have a good track record of success and then they can relax.
All right. Let’s see if we have any other questions for today, or points to share. Oh, yes. I’m curious to know if balding has anything to do with hormones.
Because I have heard you say there is a genetic component, but is there a hormonal component as well?
Well it does in that testosterone does not cause balding unless you have those genes, and a lot of women have male pattern baldness genes and until menopause there is no problem. But when they get perimenopausal or postmenopausal, if they don’t take female hormones, their male hormones become dominant because their adrenal glands are getting pushed by these very high levels from their pituitary which are trying to drive unresponsive ovaries and then their adrenal glands are making DHEA and androstenedione which are male-ish hormones and then they get bald whereas other women who don’t have these genes won’t have a problem. So, yes, there is a genetic pattern that is uncovered by the testosterone.
So just because a guy is bald doesn’t necessarily mean he has high testosterone, but it just means he has those genes which are uncovered by even normal amounts of testosterone.
Got it. All right.
All right. Well I hope this is useful in learning more about the male hormone of testosterone and andropause. And thanks Joy for participating. And if you have questions or topics you want us to address at Ask Dr. Jim Bob then send them to Joy at firstname.lastname@example.org.
All right. Thanks Dr. Jim Bob! Thanks for listening everyone – we’ll talk to you again soon!