What's New in S.H.I.N.E. — Part 9: More on Hormones
70% of men with CFS or fibromyalgia have testosterone levels in the lowest 30% of what's considered the normal range, and many 30 year olds have levels lower than most 80 year old men! For men trying to recover from CFS/FMS, bringing testosterone levels back to optimal is usually critical (more on this towards the end of the article).
But what about men without CFS/FMS? Is menopause only for women?
The answer is NO!
In a previous newsletter, I talked about menopause in women, so this week it's time for midlife and older guys to get their turn. Surprisingly, bioidentical hormone therapy at midlife and beyond can be even more positively life-changing for a man than for a woman. That's because men go through their own version of menopause (called andropause, male menopause, or "manopause") — only it's a whole lot slower and more unhealthy.
Starting at the age of 30, most men undergo a gradual, barely noticeable, year-by-year drop in levels of the hormone testosterone — from a high tide of about 1,000 mg/dL, to a low tide of 300 or even less, which is a marked deficiency. One study found that nearly 40% of men over 45 were deficient, with levels below 300.
By the time a man is 50 or 60, he may be experiencing a host of symptoms from low testosterone, and mistakenly think those health problems are just the inevitable result of getting older.
The symptoms are familiar to anyone who is or knows (or lives with) a "grumpy old man." They can include fatigue, depression, apathy, irritability, poor memory and focus, vague aches and pains, muscular weakness, low libido and erectile dysfunction. Low testosterone is also linked to many chronic health problems, including obesity, metabolic syndrome, type 2 diabetes, osteoporosis, high blood pressure, high cholesterol, heart disease and Alzheimer's.
The good news is that these problems often resolve with healthy doses of bioidentical testosterone (not to be confused with the poison that some athletes use).
In men with CFS and fibromyalgia, optimizing low or low normal (under 450) testosterone levels can be very helpful in healing. This can be done with topical testosterone or Clomid (more on this further below).
Fortunately, bioidentical testosterone therapy — the topic of this week's newsletter — is a safe and viable option for men with low testosterone. Mature men who start the therapy often report they "feel like themselves again" — with renewed energy and joie de vivre (including joie de sex).
So if you're a middle-aged or older guy who feels like somebody pulled the plug on your manhood (or you're the wife of a mature man who wonders where her husband went), read on! You may find testosterone therapy fits you to a tee! And new research shows it's safer than ever…
You may have heard that testosterone therapy increases the risk of prostate cancer. Up to a few years ago, that was the nearly universal misconception among medical professionals. New research shows that opinion is probably wrong. Very wrong.
A new study in the International Journal of Impotence Research, by scientists from the Department of Urology at Maimonides Medical Center in New York, looked at 44 studies on testosterone therapy and prostate cancer, including four studies of men with a history of the disease. None of the studies showed that testosterone therapy increased the risk of prostate cancer or increased the severity of already-existing prostate cancer.
In fact, new studies show that testosterone might protect the prostate. In a study of 156 men with newly diagnosed prostate cancer, those with the most aggressive and advanced form of the disease also had the lowest testosterone levels.
However, I also recommend taking the most conservative and responsible approach. If you begin testosterone therapy, ask your doctor to check your serum PSA (prostate-specific antigen, a biomarker for risk of prostate cancer), and to conduct a regular digital rectal exam, to make sure you're not developing the disease.
A few important points about testosterone therapy…
Make sure you're tested for both TOTAL and FREE testosterone. Many doctors test only total. But that can be misleading, because what matters is not so much the testosterone in your blood (total) but the testosterone that reaches your cells (free).
As for the goal of testosterone therapy: aim for the upper end of the normal range, or about 20-30% below the top, which is a good healthy level. For total testosterone, 750-1,000 mcg/dl is a good goal. "Normal" will vary from lab to lab, and from age to age. Most often, "normal" simply means that you are not in the lowest 2% of the population (called 2 standard deviations) — and has little or nothing to do with healthy. Sadly, some physicians are not aware of this, and confuse the normal range of a test with being healthy. If facing one of these physicians, simply ask them if they would be willing to wear a size 5 shoe, or live on $8,100 a year — both of which would be in the "normal range" medically!
My preference for the type of testosterone therapy to use? I recommend a customized testosterone cream from a compounding pharmacy, which is also usually much less expensive than pharmaceutical creams like Androgel, Fortesta and Testim — unless your insurance company covers the cost. A compounded cream is around $40 to $70 per month, compared to $300 to $1,000 per month.
If using a compounded testosterone, 25-50 mg a day is usually optimal. If your insurance covers it, get Fortesta. Both of these can be applied to the inner or front parts of your thigh (as opposed to your arms or chest as with Androgel and Testim) which decreases the risk of it getting on your wife or children. If you're thinking that it might be a good idea to get some on your wife to increase her libido, think again. Even a tiny fraction of a male dose can drive a woman's testosterone sky high. Unlike a man, where low testosterone increases risk of diabetes, in a women high testosterone increases risk of diabetes (and the risk of her sleeping with your neighbor instead of you)!
I think testosterone shots are a much less desirable option, since they tend to create too many extreme highs and lows in testosterone levels.
It is very common that high cholesterol and high blood pressure improve as testosterone levels return to optimal levels with therapy.
CFS & Fibromyalgia
Low testosterone is the rule in men with CFS & FMS, and most often their illness began before 45 years of age. Although simply giving the testosterone cream is a reasonable approach, other options are now coming available, as we'll discuss below. Whether using the testosterone topical, or the clomiphene or HCG below, bringing testosterone levels up to over 500, and preferably between 750 and 1,000 mg/dl, can markedly improve function in CFS/FMS.
Addressing Low Testosterone in Men Under 45 Years Old
Testosterone therapy will tend to lower sperm count and decrease testicle size. For those who are finished having children, this is usually no big deal. But for younger men, there are alternatives to testosterone supplementation. These include the medication Clomiphene (Clomid) and the hormone HCG, both of which stimulate your body's own testosterone production. I prefer to use the clomiphene first, and a simple test will show if it will help you.
The Clomiphene Stimulation Test for Men Under 45
If your testosterone level is low (under 450 in men under 45 years old), your physician can have you take the medication Clomiphene 50 mg at bedtime each day for 1 week. The morning after the last dose, check your total testosterone level. Over 500 mg/dl is an adequate response. Over 700 is a good response. If the response is over 500, take clomiphene 10-25 mg (they come in 50 mg pills, and may be cheaper to have made by a compounding pharmacist) 3 nights a week (each Monday, Wednesday and Friday). Oddly, lower doses often work better than higher. If your levels stay over 500 on this dosing, it is working. (For a study report on this approach, see Outcomes of clomiphene citrate therapy in young hypogonadal men.)
The clomiphene will not work in about 1/3 of cases. In those settings, I either switch to the topical testosterone creams as discussed above, or in some cases use HCG. (See HCG — A New Pain Therapy Breakthrough? for more on HCG in fibromyalgia pain. For low testosterone the dosing is lower, but beyond the scope of this article.)
When addressing low testosterone, it is good to work with a knowledgeable physician who knows how to do proper monitoring and dosing. For those with CFS, I recommend seeing The American Board of Integrative Medicine (ABIHM). The ABIHM includes over 1,500 board-certified holistic practitioners who can help you. Their website can also help you locate a certified holistic physician near you.
"Prevalence of hypogonadism in males aged at least 45 years: the HIM study." Mulligan T et al, International Journal of Clinical Practice. July, 2006. Volume 60, Number 7, pages 762-769.
"High-grade prostate cancer is associated with low serum testosterone levels." Schatzl G et al, Prostate, April 2001, Volume 47, Number 1, pages 52-8.
"Testosterone therapy in hypogonadal men and potential prostate cancer risk: a systematic review." Shabsigh R et al, International Journal of Impotence Research, January-February 2009, Volume 21, Number 1, pages 9-23.